Six blind men, one elephant and how we measure Quality in Healthcare…

The latest issue of Health Affairs contains a report about the annual cost to US physician practices of reporting quality measures ($15.4 billion). My attention was piqued by their comment that state and regional agencies currently use 1,367 measures of provider quality of which only 20 percent are used by more than one state or regional program. Furthermore, a study of twenty-three health insurers found that 546 provider quality measures were used, few of which matched across insurers or the 1,700 measures used by federal agencies.

I was thinking about how we measure quality in healthcare these days and this parable came to mind. In ancient India six blind men came upon an elephant. The first ran into the side of the elephant and said an elephant is like a wall, the second felt the trunk and said the elephant is like a snake, the third felt the tail and said an elephant is like a rope and so on, each with a “view” that was very far from the whole.

It seems to me that we in healthcare are sort of doing the same. We started by analyzing “bad outcomes” and at least advanced to blaming the system instead of the individual. Next we began looking at cost per case and advanced to at least adding in severity measures such as APR/DRGs. Separately Six Sigma and “lean” management techniques became popular. More recently we have really focused on checklists and guidelines. The latest is patient satisfaction.

All of which make me think of the elephant and the blind men. We come at Quality from many directions but often reach highly disparate conclusions. One measurement still lacking is a measure of a patient’s condition before we start doing whatever it is we do as well as a measure of how our patient is after we finish. Such a measurement would satisfy a basic tenet, that you must have a way of measuring the effects of you efforts if you are to have a meaningful quality tool.

Such a tool now exists. It is called the Rothman Index (RI) and uses a patented algorithm to create a number between 1 and 100 which represents a patient’s “overall physiological condition or reserve” irrespective of diagnosis and reflective of treatment and is based on commonly available data. It is well documented in the peer-reviewed literature and since the “patient” serves as his own control seems particularly reliable. Using this approach would allow a before and after comparison applicable to hospitals, practitioners, various interventions or medications.

I hope it is not a seventh blind man.