Precision Quality: What Cobras Can Teach Us About Quality Indicators (14 mins)

Have you ever experienced unintended consequences in your efforts to improve healthcare quality? Is there a better way to find solutions to persistent problems? This episode applies the principles of Precision Medicine -- with its individualized, scientific approach -- to the field of healthcare improvement.
Key Points:
-Viper Reimbursement
-Magic and distraction
-The garden quality indicator

References:
-Bragg, Alistair (2022). Great Moments in Unintended Consequences: Transcontinental Railroad, Cash for Ash, Cobra Problem. Reason. https://reason.com/video/2022/01/14/great-moments-in-unintended-consequences-vol-5/.
-Porter, G. (2023). Project Management. Quality for the Rest of Us: A Friendly Guide to Healthcare Quality Management. Porter Creatives.
-Drew T, Vo M, Wolfe J. The invisible gorilla strikes again: Sustained inattentional blindness in expert observers. Psychol Sci. 2013 Sep; 24(9): 1848-1853. https://doi.org/10.1177/0956797613479386.
-Lehrer, Jonah. The Magic Gasp. Mystery: A Seduction, A Strategy, A Solution. Simon & Schuster. Aug 2021. 

Transcript

Precision Quality

Sometimes our kids walk up to my husband and announce, “I have a question.” 

Given the impolite nature of this interruption, he has a sly response. He grins, slaps his hand down on his knee emphatically, and announces, “Well, I have an answer!” After a pause, he’ll add something totally irrelevant like, “The popcorn is for movie night.”

They always look confused at first, but as understanding begins to dawn on their faces, they giggle at the randomness of his answer. 

“No, that’s not what I was going to ask. Can I play on my tablet now?”

This goes on for awhile until he eventually relents and releases their tablets into their waiting hands.

It is actually quite difficult to ask good questions, and chasing the wrong question can be infinitely costly. One humorous take on this problem is a series of videos about unintended consequences.

For example, it is rumored that sometime during British rule in India, there were complaints of a spike in the venomous cobra population in the city of Delhi. As the story goes, rulers provided a generous monetary incentive for anyone who could bring a dead cobra to city officials. This promptly initiated a profitable cobra-breeding scheme, because the cost of breeding a cobra was less than the earnings from the government incentive. When officials realized the unintended consequences of their incentive program, they canceled it, which led to the immediate release of cobras from the no-longer-profitable breeding farms.[1]

In healthcare, I once read a report on an antimicrobial product. It worked great on bacteria but did not mention fungal colonies in the study. I questioned the study methods, but leadership was confident in the source. Eventually they came to the same conclusion, though, when patients began experiencing an uptick in fungal infections because the antimicrobial product killed bacteria, but not fungal spores.

We may just want patients to take their diabetes medications, but if the pharmacy compliance program actually discourages patient compliance, we need to look at those results and face them head on. We need to learn from mistakes because hindsight will always be honest with us if we were asking the wrong question to begin with.

The city officials wanted fewer cobras, not a collection of dead cobras. In healthcare, we wanted to decrease microbial burden for vulnerable patients, not increase the fungal count. The pharmacy wanted patients to show up on time for refills, not stop taking their meds altogether. Yet these unintended consequences can often help us define what we are really asking, and better yet, what we should be asking.

Most people in healthcare would not argue against a patient-as-priority philosophy, but how do we identify what matters to patients? It’s not like patients greet their doctors with questions about pressure-ulcer rates, but we all know that nobody wants a wound on their back. So how do we advocate for patients without just speaking over them?

I typically want to jump in and start solving problems, and when I see a lot of problems building up, it seems like a pointless redundancy to sit around talking about which problem we should pick from the vast supply of available issues. Talk about bureaucracy, right? We just need to get started and do something! However, experience has taught me not to rush this step. 

Why is it so difficult to identify the priority problem? Most of us know what the elephant in the room is, right? Wrong. 

Identifying the problem is the most challenging part of the QI process. Psychologists have reported a phenomenon called inattentional blindness where tasks requiring focus “can act like a set of blinders” because our brains use selective attention to focus on relevant stimuli and dismiss irrelevant stimuli.[2] This selective attention helps us solve complex problems, but it also helps magicians fool our minds with illusions and distraction.[3] 

In a clinical example, one study asked 24 radiologists to perform a routine lung nodule detection task. There was just one catch: An image of a gorilla was placed in an upper lobe of the lung scans. Did the radiologists laugh and report that there was a picture of a gorilla waving at them in the upper lobes? On the contrary, 83% of the radiologists in the study did not even mention the waving gorilla. They were so focused on the task of detecting lung nodules that they missed the big picture. Most of the time, we can’t even see the elephant in the room, much less address it. 

We should never trust ourselves when we think we know exactly what to do about a problem, and it is why we work so hard to identify the root of a problem after considering every aspect of the data. Identifying the priority problem will help identify a real solution; rather than running around wildly to fix random problems that would just happen again. 

Without a plan, our solutions would look like someone putting sunblock on a sunburn and thinking no harm will come from going back to sit on the beach all day. Clearly, the sunburn would only get worse from ongoing ultraviolet damage because sunblock was never meant to be used as a burn-healer, but as a safeguard to prevent burns from happening. 

We must focus our efforts and find the priority problem in the data if we want to use our resources effectively and see lasting success. While it is exciting to have access to data warehouses full of data, sometimes it feels like we are asking random questions without context. Whether we are exporting diagnosis-specific patient lists, mining big data or seeking answers from a ravenous data-devouring Artificial Intelligence program, the one thing we all have in common is that we are surrounded by details.

It is hard to ask the right questions, but it’s even more difficult when you are drowning in a data lake.

In some ways, it is like my friend who has autism. Sometimes, she becomes overwhelmed by the sensory experience of both eye contact and conversation, and she must look away to recalibrate. But what should we do when we are overwhelmed by patient data? How do we look away and recalibrate?

I witnessed something early in my nursing clinicals that blindsided me and helped me understand how to recalibrate:

That day, my preceptor brisked into the room with a huge smile and a cheery greeting, “It’s such a beautiful day today!”

“Really? I wouldn’t know.” The patient turned away, despondent. On his bedside table was a picture of him with a beautiful woman and two children – the wife who had left him when he got sick and the kids he never got to see anymore.

It was the first time I witnessed the prisoner-like depression that patients can experience being disconnected from the world.

We were cautioned about this in nursing school, but it seemed so unreal. Then, suddenly, you’re looking into someone’s eyes while they grapple with such overwhelming odds in their weakest physical state, and you wish you hadn’t mentioned the weather.

They told us: Be careful with comments about the outside world because patients are not part of it.

When my grandparents were recovering in a nursing home, they went for walks together every day. “If the postal workers can walk in it, then so can we,” they explained to the nursing staff as they headed out toward the garden on frigid days and icy sidewalks. It was certainly dangerous, but so was sitting inside and doing nothing. 

Grandpa pushed Grandma in the wheelchair, then when they turned to go back, they would switch, and Grandma would push Grandpa on the return trip. In this way, they formed a routine with something to look forward to, and someone to care about.

When we think about quality in healthcare, we all have opinions and ideas about what that means. I know infection control ranks high on my list, but someone else might say safe surgeries, or knowledgeable staff. When we even attempt to gather all of those quality indicators, the resulting spreadsheet is unwieldy. I had to buy reading glasses recently, not because I have any vision deficit, but because my spreadsheets are so large that I cannot view them accurately without zooming out to a tiny font-size. It’s not a great solution, but I’m glad I have an option to magnify those tiny data cells.

Certainly, as I peered over that spreadsheet, I would not have concluded that access to the outdoors was a critical part of healthcare quality.

Yet, as my precepting nurse set us up to take a trip down to the garden area later that day, I realized this stroll could be one of the most important quality healthcare moments in this patient’s entire admission. As we admired the signs of Spring that began to peek through the gray slush and frozen ground, I saw new life awaken in him as well. 

He was going to make it.

As his eyes squinted in the bright sunlight, I saw determination on his face, and he began to move with purpose, setting goals and making plans. I have no doubt his survival from cancer was linked to that stroll outside in a muddy garden.

Sometimes, when we look up from our flowcharts, process maps, reference lists and data tables, we discover that, for an individual patient, healthcare quality can be surprisingly small and simple – and listening to them can be like pulling back the curtains to let sunshine stream into the room, making everything more clear and bright. Their passing comments can be some of the most important data we receive.

Their stories can guide us if we listen. Qualitative data and patient stories are probably the most important tools to help us ask the right questions and we must not put them aside like old hardware. These real patient moments hone our questions so that we can catch hold of what really matters – the stuff that helps people get better and overcome such tremendous difficulties.

And isn’t that supposed to be the point of healthcare quality? It’s just about good scores and accurate coding, or compliance with the current protocol. All of those were built to serve patients, and without them and their personal stories, we miss the point. If precision medicine takes account for physical individuality, then precision quality must not neglect to hear those patient case studies that often baffle us because they do not fit with what we expected. Those surprises are like gold and they will help us ask better questions, achieving better outcomes.

[1] Bragg, Alistair (2022). Great Moments in Unintended Consequences: Transcontinental Railroad, Cash for Ash, Cobra Problem. Reason. https://reason.com/video/2022/01/14/great-moments-in-unintended-consequences-vol-5/.
[2] Drew T, Vo M, Wolfe J. The invisible gorilla strikes again: Sustained inattentional blindness in expert observers. Psychol Sci. 2013 Sep; 24(9): 1848-1853. https://doi.org/10.1177/0956797613479386.
[3] Lehrer, Jonah. The Magic Gasp. Mystery: A Seduction, A Strategy, A Solution. Simon & Schuster. Aug 2021.