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Extend focus beyond hospitals to truly improve healthcare

March 5th, 2014

by Thomas Dahlborg

The healthcare industry focuses on clinical quality outcomes at the hospital level, especially on preventable readmissions. Funders of healthcare implement both carrots and sticks (incentives and disincentives) to improve quality in this area; however, this sole approach is not enough.

Healthcare is a complex, adaptive system (as is each of our patients, practitioners and organizations), so a focus limited to hospital responsibility regarding care quality is not enough to truly make a difference.

For this discussion, let's expand our view to primary care as well.

Primary care physicians miss between 40,000 and 80,000 diagnostic opportunities per year, which lead to considerable harm to patients, according to a study published in the Journal of the American Medical Association. These missed diagnoses often include serious illnesses, such as acute renal failure, pneumonia, cancer, angina, cellulitis, hypertension and urinary tract infections.


Hardeep Singh, M.D., chief of the Health Policy, Quality and Informatics Program at the Houston Veterans Affairs Medical Center and associate professor at Baylor College of Medicine, recommends the following as possible solutions: "physicians' greater use of electronic decision support tools and mandatory, structured recording and coding of presenting symptoms, rather than simply diagnoses." At a minimum, he believes these improvements "would help healthcare systems better track these errors."

Expanding healthcare system improvement and a focusing on relationship-centered care, which cherishes patients and families and honors their preferences throughout the healthcare continuum, would be even better.

More than a century ago, William Osler urged his students at Johns Hopkins and Oxford to "listen to the patient: He is telling you the diagnosis." More recently, as noted in BMJ, the system acknowledges that the "correct treatment recommendations require accurate diagnosis not only of the medical condition, but of patients' treatment preferences."

But how can a doctor recommend the right treatment without understanding the whole patient and the values the patient places on the trade-offs that may occur based on the treatment course selected (not to mention socioeconomic and other barriers to patient activation)?

How can doctors best understand the whole patient and truly engage both patient and family?
We must create a relationship-centered healthcare system that allows for time, continuity and relationships so patients and clinicians can develop trust. Only when we have this relationship focus will we receive and understand the patient's whole story.

Providers must assess and develop cultural competency skills, especially primary care clinicians. They also must leverage tools like emotional intelligence and motivational interviewing to ensure optimal sharing, and that the patient and family preferences are heard and understood.

Once we create this system where:

  • the patient and clinician are in an authentic trusting relationship
  • the patient's whole story is shared, heard and known
  • the patient and family are engaged
  • the level of patient activation is understood
  • the patient preferences are known

... then and only then can providers truly honor the patient. Only then will doctors and patient co-create, implement, study, modify and assess a care pathway. Only then will we be best positioned to arrive at an accurate diagnosis and correct treatment recommendation where the patient is 100 percent involved and best positioned to achieve. Only then will our patients be honored, cherished and safe.

Yes, we need to address patient safety issues at the hospital level and throughout the system. And yes technology and checklists are essential tools in healthcare.

But without a system change, which allows for relationship-centered care, we will continue to harm our patients. We can do better.

Thomas H. Dahlborg, M.S.M., is chief financial officer and vice president of strategy for NICHQ (National Institute for Children's Health Quality), where he focuses on improving child health and well-being.


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