When the Institute of Medicine’s Committee on Quality of Health Care in America, of which I was a member, published the landmark report To Err is Human: Building a Safer Health System in 1999, I was working in New York as department chair of geriatric medicine at Mount Sinai School of Medicine, so I got the cold calls early that morning to appear on the news shows. The report prompted a lot of interest with its estimates of up to 98,000 deaths every year from preventable mistakes in hospitals.
Our recommendations focused on ways the systems of care could be redesigned to reduce the likelihood of errors. The message “to err is human” was intentionally meant to say that in the complex world of modern medicine, error cannot be totally prevented by individual clinicians, no matter how well trained or how vigilant they may be. In spite of that message, many reporters at the time were relentlessly focused on the question: “How can the public find the bad doctors?”
Media coverage of healthcare quality has become much more sophisticated since that time. And huge amounts of performance data now surround us. There have been advances in measurement science, proliferation of “report cards,” and growth in accreditation and certification organizations of various sorts. These are now linked to payment in many ways, and we have seen progress in quality of care in many domains. But using performance metrics to evaluate individual doctors and pay them for “value” is fraught with problems.
The performance of a physician or advanced-practice clinician involves so many different dimensions of competence, knowledge, skills and emotional intelligence that it is hard to imagine five or 10 specific publicly reported measures will capture the quality of care delivered. More importantly, clinicians everywhere are now part of teams and systems. Care of the patient depends on many people and technical resources controlled by delivery systems and organizations. The metrics are necessary to help the team and the system know where they should focus on improvement, but those metrics don’t really paint a picture of the individual doctor or nurse.
Some experts believe that the attention to measurement and pay for performance has obscured more fundamental drivers of quality that would enhance the intrinsic motivation of the human beings on the front lines of care, and create more patient-centered coordinated care. Perhaps the adage “to err is human” also applies to the many well-meaning policies and procedures we’ve put in place in our efforts to drive safety and quality.
The National Academy of Medicine (previously the IOM) released another report this year that marks the next challenge for healthcare quality: clinician well-being. Documenting high levels of burnout among doctors, nurses and other clinicians, the report points to the complex systems and bureaucracies that clinicians have to navigate and recommends human factors analysis and systems engineering approaches to reduce the barriers to the effective and fulfilling work of patient care. Like To Err is Human made clear 20 years ago, we do not see the answer solely in increasing resilience of individual clinicians, but call on leaders, managers and policymakers to develop the road to relief.
There are many factors leading to the stresses on clinicians, and some of them stem from demands for performance measurement and documentation for billing. While this isn’t the only factor, information technology creates more demands, not fewer. We must now ask ourselves how much of this information is truly useful, and how much could it be reduced or technologically streamlined? Over the coming decade, advances in the use of artificial intelligence, machine learning and cloud-based information systems should also help to remove much of the drudgery and frustration surrounding clinical practice, and allow clinicians to experience joy in the ability to use advanced science combined with their fundamental humanity to connect with our core mission of healing and caring.
Dr. Don Berwick, when he led the Institute for Healthcare Improvement and as administrator of CMS, championed the “Triple Aim”—advancing quality care, population heath and affordability. The new construct, the “Quadruple Aim,” recognizes that the well-being of the healthcare workforce is necessary to achieve the other three.
