Metric

I'm not a great fan of performance indicator, particularly those key performance index in our hospital setting. It's really about a quality metric that is worse than useless.

It is often the case that hospitals struggle to get a better score to prove their quality. But the score might tell otherwise. The performance score runs lower and lower, unlike the hospital team's anxiety that swelled and swelled with each passing day. So eager we're to fulfill the quest of performance index that we strive for the top score by hook or by crook.

The obsession with scoring system is understandable. The scoreboard has been in place for all of us in school, from clan to clan, culture to culture, and it is embraced earnestly and repeatedly. The hard truth is, most parents believe in the score. Some students, and many teachers, do. An important and oft-quoted metric on the scoreboard is the "intelligence quotient." But there's an old parable in which two cavemen were frightened when the earth shook with each footfall of a grumpy sabre-toothed tiger. The first caveman named Ug, with his mathematical and logical intelligence, tapped his chin and calculated the angle from which the tiger is approaching to the nearest degree. His mate, Thug, with the bodily or kinetic intelligence, ran away. "Who's the clever one now? Ug or Thug?"

I will say that, whether you're a parent or a hospital manager, should not miss the article "Performance Anxiety - What Can Health Care Learn from K-12 Education?" published recently in the New England Journal of Medicine. So, then. You will see how similar the health care and education system have been misled by the shortsighted performance measures. Examples of the top-down performance measures at school: students' achievement in standardized mathematics or reading tests, teacher's certification status. Just as how physicians lose performance points when patients cannot meet certain performance targets because they were dealt bad genetic and environmental hands, teachers are hold accountable for students' varied developmental timeline and many other uncontrollable factors in their lives. In turn, the author proposed a new bottom-up performance measuring system that, for instance, looks at the discussion and questioning skills, ability to engage students in learning, the expectation that students will correct their mistakes. The proposed measures to be assessed in hospital are similar: measures of patient experience such as effectiveness of physician communication about diagnosis and treatment.

Still, in the presence of pay-for-performance programs, many of us will pay more attention to the top-down performance measures. One good example of such outcome measures is the complication of venous thromboembolism after surgery. That's referring to a blood clot that forms in a vein deep in the body. It's a neat trick to blame and punish the "bad apples," referring here to those hospitals with more event rates of venous thromboembolism. Is it that simple? A new study, using data for nearly 1 million surgical discharges from 2800 hospitals, makes a solid argument against this measure. To cut the story short, the venous thromboembolism rates simply reflect how aggressively doctors look for them, but probably are not directly related to quality of care.

In other words, because some doctors more aggressively look for complications, they find more and appear to have worse outcomes. Good lesson to learn.