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Bird Boxes and an Elephant’s Butt: What we talk about when we talk about quality

January 21, 2019

Yanking on the firm muscular tail, the first blind man yelled, “It’s a rope!” The second stretched his arms partly around one of the legs and shouted, “No, it’s a tree.” The one in front of the tusk recoiled in surprise, shaking his head that the others couldn’t recognize a spear. His friend pushed along the side of the great beast and proclaimed that he had found a wall, while the last one held the trunk and thought the others crazy for missing a snake.

Looking at one aspect from the parable of the blind men and the elephant shows us that there are many interpretations of the same thing. In healthcare this is just as true. Let’s look at quality – we all want it, but because of our individual perspectives of what quality looks like, how often are we actually talking about the same thing? Or are we unwittingly participating in a healthcare Bird Box challenge?  

It is easy to see how this can manifest in controversy: Guidelines differ on the starting age of mammograms, optimal levels of A1C and blood pressure, and what to do with statins. Doctors advocate for resources to provide the right care, governments try to avoid rationing healthcare while staying within budget, and health authorities choose to collaborate or go alone

Personally, I think doctors most often equate quality with both effectiveness (doing the right thing) and efficiency (doing things right). But as we expand the scope and look at other factors that make for a Quality System, we can see how these two factors can conflict. Patient-centeredness is one aspect of quality, but may drive up cost through the demand for inappropriate testing. Timeliness of care is also important, but likewise, requires investment in the short-term while the downstream benefits – improved quality of life, decreased pain, and faster return to functioning – often extend past political cycles. We all want to work in safer environments, but hygiene and culture have time and up-front financial costs. Lastly, equity is another aspect of quality care that deserves consideration.

So as we talk among ourselves, and meet with politicians and administrators, it is important to keep in mind that while we may all recognize a quality healthcare system when we see it, we must be clear on our principles and priorities. Because without knowing exactly where we are going, we could easily end up at the wrong end of the elephant.


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