Simple Metrics Useless for Medical Care Processes

Health bureaucrats talk out of both sides of their mouths – Richard A. Young, MD | June 20, 2017

In our recent paper criticizing how industrial quality improvement [posted below] has been misapplied to primary care, we didn’t just complain, we made suggestions for a better way forward.

regulators and payers will continue to insist on some kind of numeric reporting of outcomes by physicians or practices whether physicians like it or not, or whether it’s really useful and fair or not.

Bureaucrats talk out of both sides of their mouths. They say they want care that is patient-centered, but if one of my patients doesn’t want to do what the textbook says should be done for a simplistic situation, I’m supposed to bully them into receiving care they don’t want or need just to make my report card look better. 

Soon it will be more than looks. Physicians’ pay will depend on pleasing the simplistic report card gods.

It’s just wrong.

Below is the paper about the foolishness of using simple metrics for complex processes, like medical care.

The Challenges of Measuring, Improving, and Reporting Quality in Primary Care – Ann Fam Med March/April 2017 – Richard A. Young, MD1,  Richard G. Roberts, MD, JD2 and Richard J. Holden, PhD

We propose a new set of priorities for quality management in primary care, acknowledging that payers and regulators likely will continue to insist on reporting numerical quality metrics.

Primary care practices have been described as complex adaptive systems. 

Traditional quality improvement processes applied to linear mechanical systems, such as isolated single-disease care, are inappropriate for nonlinear, complex adaptive systems, such as primary care, because of differences in care processes, outcome goals, and the validity of summative quality scorecards.

Our priorities for primary care quality management include

  • patient-centered reporting; quality goals not based on rigid targets;
  • metrics that capture avoidance of excessive testing or treatment;
  • attributes of primary care associated with better outcomes and lower costs;
  • less emphasis on patient satisfaction scores;
  • patient-centered outcomes, such as days of avoidable disability; and
  • peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.


The US National Quality Strategy has 3 overarching aims:

  1. improve the quality of care,
  2. improve the health of the population, and
  3. reduce the cost of care.

The achievement of these aims depends, in part, on the collection and reporting of quality measures, more than 400 of which are endorsed currently by the US National Quality Forum

Supporters of quality metrics and physician scorecards, such as those required for patient-centered medical home (PCMH) certification, assume that better health can be achieved by following guidelines developed for single diseases, and that a summation of single-disease guidelines accurately describe the quality of work delivered by a primary care practice.

These assumptions are aligned with traditional strategies for process and quality improvement (QI), such as Six Sigma and lean thinking, that have been powerful tools in mechanical systems and disease-specific care processes.

Many people think that systems are improved by deconstructing the overall system performance and management into component elements.

In contrast, primary care is better conceptualized as a complex adaptive system—where learning people and institutions (“agents” in the complex adaptive system vernacular) interact with the environment in nonlinear patterns and self-organize, resulting in unpredictable, emerging creative behaviors rather than rigidly adhering to a standardized set of linear processes for diagnosing and treating single diseases.

Failure to appreciate these complexities leads some to erroneously conclude that practices have failed by not implementing standardized interventions.

Well-aligned quality measures for primary care should promote accountable performance and boost clinicians’ motivation by rewarding them for managing complexity, solving problems, and thinking creatively when addressing the unique circumstances of each patient.

Instead, misaligned QI metrics and other mandates as electronic health records (EHRs) have contributed to burnout among physicians, especially those in primary care, causing some to advocate for the Quadruple Aim by adding the goal of enhancing professional satisfaction and well-being to the Triple Aim.

Most importantly, many primary care physicians believe the existing metrics may paradoxically encourage poor quality of care

Given primary care’s central role in health care, we believe that the inappropriate application of traditional QI strategies and misaligned metrics undermines primary care, and in turn, all patient care.

We challenge the notion that care process strategies, outcome goals, and reporting devices that may work in mechanical areas of health care are valid in primary care.

We offer alternative approaches that we believe will better support primary care’s important responsibilities in helping us achieve our national quality goals.

Richard Young is a family physician who blogs at American Health Scare


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