The Third Dimension of Quality Improvement
Jul 6 2021 - Russell Kohl, MD, FAAFP
Quality improvement (QI) efforts have long been modeled as an interplay between “competency” and “commitment.” In this model, a subject is evaluated for their knowledge-based attributes (the knowledge or technical gaps that must be addressed in order to move forward), called their “competency,” and their attitudinal attributes (the cultural traits or belief systems around both the topic and change), called their “commitment.” However, the last year has shown an additional dimension, called “competition,” which should be included in the model. The ability to maintain ongoing QI efforts during COVID-19 presented a great challenge to many health care organizations. These organizations hadn’t lost competency and they remained just as committed to achieving the best for their patients as they were before the pandemic. They simply couldn’t maintain their prior “full-time” health care work in addition to the expanded demands of the pandemic. The competing priority of the pandemic entered into the dynamic, which requires us to reflect on our mental model of competency versus commitment in quality improvement.
To imply that the competition for resources required during COVID-19 is new, would be fallacy. Every health care organization has done this sort of mental triage for years. The difference is that the “normal” timeline of QI projects (and even the conceptualization of QI as a “project”) has historically led to these triage decisions being attributed to the “commitment” domain. As QI projects were proposed, the health care organization historically decided it couldn’t commit to it, based on capacity. During 2020, though, many organizations found themselves having to set aside ongoing projects that they continued to feel strongly about. While stopping a project effort versus not starting one are generally the same from an ethical perspective, they certainly don’t feel like it from a humanist point of view. Ongoing QI projects with positive results had to sometimes be set aside to return to the survival stage of Maslow’s Hierarchy of Needs. What can we learn from these situations and how should this affect our conceptualization of quality improvement moving forward?
My immediate recognition was the impotence of many of our current methodologies for defining quality. Instead of a holistic, patient-oriented approach to QI measurement, we have continued to perpetuate a disease- and procedure-based measurement and evaluation system. How do we reconcile quality when the disease we were measuring ceases to be the patient’s greatest risk factor for premature mortality and morbidity? Is it really “poor quality” to change our focus to the higher risk (such as spread of a virus like COVID-19) and place our previous QI work on hold? Is the organization really “plateaued” when its measures aren’t improving, but its patients’ mortality/morbidity risks are decreasing due its actions? These challenging questions, and the sheer scope of the COVID-19 pandemic, refuse to allow us to return to a QI model that doesn’t adequately consider competing demands. We can’t let competing challenges (like those presented in a pandemic) be swept into the domain of “commitment,” where we view patient oriented prioritization as a “lack of commitment to improvement.” We are left with a profound, but simple question: “How do we determine what’s most important to care for patients at this moment?”
Too often, this question is answered based on finances. While acceptable if we are certain that financial incentives are correctly aligned, experience would suggest that they are frequently not. Patient preferences could be an additional criteria, however this criteria may challenge the entire premise of population health. How, then, do we determine prioritization of efforts for quality improvement? While I don’t yet know that answer, the importance of recognizing prioritization as a separate driver of QI efforts is the first step towards identifying all dimensions of quality improvement.
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