CANADA: Quality, not just quantity, of care matters

We need to ask patients about how they're being treated - and to listen to what they say By Andre Picard, Globe and Mail, Toronto, April 3, 2008: In our endless discussions about health care in this country, the same questions are posed over and over again: How much money is being spent? How many doctors are available in specific areas? How many surgical procedures are being done? How long is the wait? These are all questions of quantity. We don't spend nearly enough time or effort discussing the quality of care. And we almost never ask patients - the consumers of health care - if they are satisfied with their care. Quality, of course, means different things to different people. Some value easy access and speedy care; others place a high importance on being treated courteously and professionally; for some, what matters is the amount of time spent dealing with their health-care issue; others emphasize safety. And, of course, outcomes matter - having your health problem dealt with satisfactorily. The old expression, "I don't know art but I know what I like," has a definite parallel in health care. There may be no single definition of quality care, but patients know when they have been treated well. We know too - anecdotally and scientifically - that quality care pays dividends: It helps you stay healthy longer and recover faster. But when was the last time anyone asked about the quality of your care? That is why data released this week by the U.S. Department of Health and Human Services is noteworthy. The HHS published the results of a massive survey of patient experiences and perceptions of hospital care for all the world to see (hospitalcompare.hhs.gov). While the data are from the United States - where the health system is different from Canada's - they are still informative and fascinating. The survey asked a series of questions about everything from the cleanliness of bathrooms and noisiness of hospital rooms to the quality of information provided by doctors and nurses. What Canada has now is data on hospital mortality rates, which is useful but has limitations. There is no reason Canada could not do this kind of patient satisfaction survey, and hospitals could be easily enticed with some financial incentives. (In the United States, hospitals that refuse to conduct and publish satisfaction surveys have a portion of their medicare payments withheld.) Over all, in the HHS survey, patients ranked their hospital care quite high: 63 per cent gave their hospital a ranking of 9 or higher on a scale of 10. But patients were highly critical of their care in three key areas: They complained about not being treated with courtesy and respect by doctors and nurses. They felt pain medication was inadequate after surgery. They often did not understand instructions they were given when discharged. These are significant matters that can have a direct impact on recovery and on health in general. They are also all issues related directly to proper communication. In the health-care setting, there is a lot of rhetoric about patient-centred care and about the need to have patients engaged as active partners in their care. But you can't be fully engaged without sound, comprehensible information. And you can't be an active partner if you're subjected to discourteous monologues rather than respectful conversations. The issue here is not merely that Miss Manners has a lot of work to do in the health-care setting. Doctors and nurses who do not listen carefully or explain clearly are not merely a source of irritation, they are causing real pain and suffering. Poor communication is, among other things, a major source of medical errors. That being said, the clinical quality of care remains primary. It is not sufficient for health-care practitioners to be friendly and listen to patient complaints; they have to be able to fix "the problem" efficiently. But these issues are not mutually exclusive. A brilliant clinician can be even more effective with decent explanations; a superb surgeon will have better outcomes with comprehensible instructions at discharge. Good communication - which runs the gamut from high-tech electronic health records through to old-fashioned face time with the doc - is empowering for both the provider and the patient. But it doesn't just matter to individuals. Listening to patients is also critical to improving health-care delivery and keeping the system honest. There is some good evidence that hospitals and individual health-care practitioners who communicate well have the best outcomes. If the term patient-centred care is going to have real meaning, it is important to listen to patient experiences, to make that information publicly available, and to act on it. But the starting point is asking, and listening. © Copyright 2008 CTVglobemedia Publishing Inc