Aug 24, 2014

Of Measures and Men

News about the Veterans Affairs (VA) scandal this summer coincided with my being in the midst of reading Daniel Pink’s ‘Drive: The Surprising Truth About What Motivates Us’. Pink’s chapter on unethical behavior seemed uncannily relevant as it described how a carrot-and-stick approach to motivation can encourage cheating, shortcuts and unethical behavior.

The VA reported that patient wait-time data had been falsified in two-thirds of its health care facilities. Organizational leadership failure, an unfocused performance measurement system, a toxic milieu, and unrealistically high goals, that placed undue pressure on staff and promoted unethical practices were cited as key causes.

Several unintended consequences of the VA performance measurement system, mostly related to local implementation methods, were also described back in 2012 by Powell and colleagues.

Performance measurement faces even greater challenges in my own specialty, pediatrics. Pediatric measures tend to be predominantly process measures with sometimes less clear correlations with long-term clinical outcomes and population health. The evidence base for pediatric measures is even less mature than for adult measures, no pun intended.

Performance metrics are essential in tracking outcomes. You can only manage what you measure. And in health care, where demands on scarce resources are increasingly, quality measures are an indisputable way of figuring out which processes need to stay and which can go. Problems begin when performance measures cease to become a means to an end, and become an end unto themselves.

A Robert Wood Johnson Foundation-Urban Institute report advises strategic and parsimonious use of quality measures, recognizing when performance measures are not clinically valid or useful, and recognizing that performance measurement is just one aspect of a learning health care system.

My involvement these days with Central Line-Associated Bloodstream Infection (CLABSI) prevention is demonstrating to me even more strongly the importance of organizational context such as local culture, leadership styles, clinician engagement, and intrinsic motivation in applying quality measures. On hindsight, the training video on CLABSI measures that my team just finished working on probably needed to include a footnote on the perils and pitfalls of performance measurement. And that CLABSI is in essence a social problem that demands a focus not just on tracking infection rates, but on human behavior within complex and intense environments.

Front line clinicians need to remain accountable for their actions. However, leadership and an organizational culture that enforces rigid top-down measures without attention to providing resources and investing in developing people promotes the systemic infusion of unethical behavior and short cuts.

- Ulfat Shaikh

Measuring Improvement in Health Care from Ulfat Shaikh on Vimeo.

May 18, 2014

If I could do one thing to make the world a healthier place

As a pediatrician, it is sobering to realize that the factor with the highest impact on my young patients' health is not a clinical breakthrough. It is whether they and their parents complete high school. Even after taking income or race into account, educational attainment, or the years of schooling an individual has, remains one of the strongest social determinants of health.

People with more years of schooling don’t just prosper. They live longer. They exercise more, eat healthier food, don't smoke, get regular health care, and have better health outcomes. College graduates live at least 5 years longer than people who do not finish high school.

The effect of education is pronounced when you look at female education. Women with

Mar 24, 2014

How to Build a Health Care System from Scratch: Revisiting New Orleans Ten Years Post-Katrina

“My friend was a neurologist at a hospital in New Orleans”, my daughter’s art teacher told me when we were chatting at pick-up time about my upcoming trip to New Orleans. “She lost her home in Katrina”, she continued. “The stories she told me about how they cared for all these patients
in the hospital with no electricity and water and barely any resources were just plain scary”.

My last trip to New Orleans, Louisiana, was in 2003, two years before Hurricane Katrina. My personal agenda for the trip included crawfish, shrimp po’ boys and cafĂ© au lait. Now, more than a decade later

Feb 1, 2014

How a Fishbone Can Help You Eat Your Veggies

February is here and it is possible that a few of you, like me, are already rethinking your new year’s resolutions. What seemed a month ago like a sure-fire plan to lose 10 pounds, exercise more, eat healthier, or manage ones finances, now seems a little more suspect. Let's view this bump in the road, not as a reason for despair, but an opportunity for improvement. 

I teach a class on health care quality called “Personal Quality Improvement”. The class incorporates process improvement techniques

Dec 27, 2013

So Far and Yet So Near: Virtual Quality Improvement Networks in Health Care

Membership in the global Indian diaspora comes with a price, and my family and friends use Skype and FaceTime with regularity to bridge distances. It then comes as no surprise that health care is now using similar communication technology to provide better and safer patient care.

A few months ago it was reported that the majority of the 150 hospitals in the