As board chair of a community hospital, I am often confronted with the dozens of quality and safety measures that state and federal regulators use to score and pay us, and private organizations use to rate us. And as someone who works to improve the quality of care for older adults, I am struck by how much all these measures miss when it comes to what really matters for seniors.
Here’s an example: Imagine an 85-year-old widow with mild dementia who lives alone at home. She comes to the emergency department of her local hospital with severe hip pain. She is treated quickly and efficiently in the ED. The orthopedic surgeon finds that she has severe arthritis and determines the best treatment is hip replacement surgery.
The surgery goes well. There are no complications. She gets no infections of any kind. She never falls during her hospitalization. All her doctors wash their hands coming in and out of her room. She gets a flu shot and a vaccine to lower her risk of pneumonia. Her pain medications are administered appropriately (not too much and not too little). Her nurses quickly respond to her call bell and her food is hot. With her permission, her daughter, who lives out-of-state, is kept well informed of her condition.
After a few days, the patient is discharged to a skilled nursing facility for rehab, and is not readmitted to the hospital for any reason directly related to her surgery. After a time in rehab she goes home. Her surgery and hospitalization went smoothly. Everybody did their job and the hospital will get a great score based on all those required metrics.
But did all that highly-rated medical treatment improve her life? Is she, in the most important sense, better off than before her surgery and hospitalization? Those questions are not so easily answered, and they largely are never addressed by all the star ratings and other quality and safety measures that hospitals must manage.
For example, could the patient have had a better outcome if, instead of hip surgery, her pain was better managed and she was encouraged to lose weight and make modest changes to her lifestyle?
What if her hospitalization adds to her already-existing confusion and her dementia worsens? What if, after she goes home, she is unable to do physical and occupational therapy (perhaps because she can’t get to the therapist, or because she can no longer count to 10, thus can’t keep track of the number of leg lifts she is supposed to do)? What if she can’t walk the five steps from her front door to the street? Or can no longer cook for herself? What if she becomes depressed as result of all these limitations? Does she have the social supports she needs to live safely at home?
Who asks those questions?
These ratings are often described as measuring quality and safety. In truth, they really measure only safety. And they are much more likely to focus on process than on outcomes. That’s not surprising because process is so much easier to track, especially for older adults. Falls can be counted. Happiness cannot.
Hitting The Metrics
Don’t get me wrong. These ratings are an important screen for anyone choosing a hospital or nursing home. No one should be treated in a facility that is unsafe. But they miss a lot that is critical to understanding the well-being of a patient.
They also result in opportunity costs. Hospitals are obsessed with hitting government metrics and satisfying the scorekeepers at national magazines or consumer groups. But they often lose their focus on what really matters: delivering care that improves their patients’ well-being—but isn’t measured.
Not falling is good. But is not the same as having the best possible quality of life.