Do things right, or Do the right thing?

Two weeks ago, when I started writing about the Mayo Clinic, most of the feedback I got was favorable. It seemed that people were glad to read good news for a change. But Ian Hendra, of Clearline Services in New Zealand, offered a comment on LinkedIn that was very critical, not only of the Mayo Clinic but of the whole health-care industry. The gist of his argument was that medical care as practiced these days focuses (outside of surgery) on the use of pharmaceuticals, even for conditions that can be more thoroughly and reliably treated with diet and nutrition. While his comment rapidly plunged into detailed arguments about diet and insulin resistance, he touched on a wider issue. If I were to rewrite his argument to make it at once more general and more focused on the underlying Quality topics, it would sound something like this:

Any hospital whose Quality Policy says they prioritize patient outcomes should do everything they can to help patients get well. But this means they should use methods that have (1) a high rate of success, while involving (2) minimal intervention in the body's natural operation, in order to cause (3) the fewest unwanted side effects. Many of the treatment methods common in modern medicine, by contrast, involve significant intervention in the body's natural operation, and sometimes trigger serious side effects. Therefore a hospital who takes the Quality Policy seriously should step back from many of the most common treatment methods in modern medicine, and replace them with others.  

Now, I'm certainly not a doctor, and I have no expertise to discuss this critique at the medical or scientific level. What is more—to be very clear—I don't know the research that Mr. Hendra is relying on, so I have no idea whether he's got his medical or scientific facts straight. But what interests me is the Quality issue. If some patients do better when they are treated according to nonstandard methods, does Mayo's Quality commitment require its doctors to adopt those nonstandard methods? Is that what a commitment to the Quality of patient outcomes really means?

In one sense, of course it would be nice. From a patient's point of view, getting well is typically the only measure of the Quality of a course of treatment. At the same time, there are a number of pragmatic considerations that every hospital or medical center has to keep in mind.

They have to have specialists who understand any method of treatment that they offer. The more types of treatment they offer, the more specialists they need in different fields. This point should be uncontroversial, but we can't forget it.

The treatment methods they offer have to be known to work. This point is trickier than it sounds. Human health is phenomenally complex, and even the most routine courses of treatment regularly fail on somebody. It's also true—and documented—that some very unusual courses of treatment have nonetheless worked very well on some patients.* It can be hard to know where to draw the line, but you have to draw it somewhere; otherwise, with no regular approaches, a doctor really doesn't know where to begin.

Finally, the treatment methods often require not only consent but active participation (or at least compliance) on the part of the patient. This is where diet and nutrition encounter their most frequent difficulties. Most patients are famously very bad at following nutritional advice. Lots of people "know they should eat better than they do," but that doesn't change their food choices in real life. If a doctor says, "Take this medication once a day for two weeks," patient compliance is usually pretty high. If the same doctor tells the same patient, "Cut out high-cholesterol foods and refined carbohydrates every day for the next thirty years," compliance drops off fast. You don't have to look for conspiracies by the pharmaceutical industry to guess that there are practical reasons doctors overwhelmingly choose the former approach over the latter.

In light of these considerations, what is a hospital to do? At a pragmatic level, as I suggested a minute ago, they have to draw the line somewhere. Implicitly or explicitly (and of course it is better to do  it explicitly) they have to say, "These are the kinds of services we provide. We will provide them as well as we can. But if you want some other kind of service, you have to go elsewhere." This statement defines the Scope of their Quality System. Inside that Scope, it is possible to optimize their performance. But there is no meaningful way to optimize performance of tasks that are outside of Scope, because a hospital (or any organization) shouldn't take on those tasks to begin with. And if you try to widen your Scope until it covers everything, you can never optimize because you can never get your arms around the task. So you can never get started. 

From  Matt Groening's School is Hell.

To capture this in a snappy formula, an organization's Quality Commitment is focused on ensuring that the organization does things right, and not that it does the right thing. There must, of course, always be room somewhere to discuss whether the organization really is doing the right thing, or whether the Scope should be amended to include new and different kinds of activities. But these discussions take place necessarily outside the Quality System (though they might incidentally involve some Quality personnel). In a hospital, these discussions would include whether to offer or adopt fundamentally new or alternative forms of treatment; in a business, they would involve whether to pivot to a new line of business or a new form of operation. These discussions are important but they are fundamentally strategic, while most routine Quality work is tactical: Given a certain set of objectives, how can we best achieve them?

No Quality System will ever make everything perfect, any more than it can prevent all accidents ever. And it is not really the job of the Quality System to break the paradigms in which the organization operates. But inside those paradigms, of course, it is a powerful tool for making things as good as possible.

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* In addition to the normal kinds of care made available by conventional medicine, there have been documented cases where some patients have responded well to such treatments as: 

• diet and nutrition (Mr. Hendra's preferred approach)
• placebos
• acupuncture
• homeopathy
• Christian Science practice
• laying on of hands
• prayer  

Obviously it would be tough to ask a hospital to provide all of these.