You are Number 1!

“We’re number 1!  We’re number 1!”  We heard that a lot after the summer Olympics, though not so much these days after a Packers game.  It doesn’t seem too incongruous at a sporting event, but I have to admit it feels kind of cheesy when applied to where we work.  And when it comes to the hospital, what exactly does it mean, anyway?  The last time Parents magazine did a ranking, in 2009, they rated CHW the third best children’s hospital in the country.  That felt pretty darn good.  (We are currently gathering data for their new survey, and hope to be ranked at least as highly.)  In the 2011 US News and World Report survey (we were unable to collect the necessary data to participate in 2012 because of the demands of preparing for Epic), we were not even among the top 10, though we ranked in the top 35 in all 10 specialties evaluated.  So what’s that about?  Part of it is that a large percentage (about one-third) of the US News ranking is based on “reputation,” which is at best subjective.  But perhaps it also reflects how hard it is to measure quality.

Not that it has stopped people from trying.  Whether it is or Angie’s list, which simply allows patients to post their anecdotes; proprietary services list MD Nationwide that pull together “data” on physician quality; or payers like United Healthcare’s Premium® designation, there is no shortage of ways for our “performance” to be reported on.

Even for the well-intended, one challenge is that quality is multi-dimensional.  I think we’re all pretty familiar with the IOM quality domains: effectiveness, safety, efficiency, timeliness, patient-centeredness, and equity.  Most providers have traditionally tended to emphasize effectiveness to the exclusion of other dimensions, but I believe that view has begun to change.   Even so, we tend to be skeptical of efforts to measure and report on quality (perhaps understandable given some of the sorry efforts already noted).  Some aspects of quality are things we can measure directly (e.g., cardiac surgery survival rates, central-line associated bloodstream infection rate, wait times, family satisfaction), others by (admitted imperfect) proxy (e.g., provider training and qualifications, staffing levels).  But in the end, even these things are problematic.  What are the best indicators of efficiency?  If there is a trade-off between two different aspects of quality, how do you decide which is more important?  The answers may depend in large part on one’s point of view.  Coming up with a simple composite that allows one to rate hospitals or providers seems, well, simplistic at best.

Or is it?  Perhaps, as Supreme Court Justice Potter Stewart famously said of pornography, “I cannot say what it is, but I know it when I see it.”  I rather like the definition provided by Louis Graff, an emergency physician: quality is “the care health professionals would want to receive if they got sick.”  So while I don’t want to minimize the importance of outside perspectives, regardless of what Parents magazine or US News ends up deciding (and I do appreciate those who have worked to gather the data for those surveys!!), I know that what I see every day at Children’s meets that last definition of quality.  You are number 1!

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