Don't Lose Sight of Quality

by Seth M. Hardy, MD

This article was originally published in the Journal of the American College of Radiology - Volume 12, Issue 7, Pages 696-697


Imagine the following scenario at your hospital. Management begins a very large merger and capital-building campaign that consumes the limited human resources at your institution. Faced with the overriding mission of this campaign, staff members begin to lose sight of providing quality care. Good staff members are pushed beyond their capacity to perform. Patient care suffers, and patients are harmed. Outstanding members of the medical and nursing staff, who are well known in the community, quietly leave the institution for competing hospitals.

A minority speaks up, but as employees they are stripped of their leadership positions or fired. The CEO starts whispering in the ears of department chairs, “What is wrong with Dr X?” and your partners ask you to remain silent. Worse, the chief medical officer weaponizes the disruptive physician policy, which states, “impertinent and inappropriate comments…or other official documents (ie, e-mail) impugning the quality of care in the hospital [shall be considered disruptive].”[1] Concerned physicians not only fear for their jobs but now also fear for their careers, as they can be reported to the National Practitioner Data Bank for being disruptive. Authority gradients steepen, there is no “culture of safety,” and the concept of quality becomes opaque and murky.

Quality Reenvisioned

Much has been made of quality in health care recently, particularly with the advent of accountable care organizations (ACOs), whose mission it is to reduce costs and improve quality. Many physicians are passionate about patient care and take quality very personally. Yet this commitment by individual physicians does not translate very well at the system level. Medical systems are increasingly being asked to report quality and to objectify system performance against metrics by Medicare, Leapfrog, ACOs, and payers. Increasingly, payment is linked to these metrics, and in the case of ACOs, the system is at financial risk if these metrics are not met. Faced with poor margins, a health care system’s survival becomes dependent on these metrics.

Many of these metrics are process measures. They are used because they are easy to obtain from our electronic health records or claims data and are simple to compare nationally. Many revolve around single diagnostic or treatment codes, and few measure actual outcomes. Extrapolating a few codes as markers for the global quality of a health system is not statically valid. Furthermore, developing outcome measures for every diagnosis across a health care system and then the nation is logistically impossible. Some of these metrics are self-reported by health systems. If a health system dares to silence its members’ concerns regarding quality, might they also be unethical enough to bias these metrics?

We must remember that the quality of a health system is not only important for reimbursement but is also critical for our families, friends, and neighbors. In addition, quality is important in the brand equity of that health care system. Brand equity can be defined as “the set of assets (or liabilities) linked to the brand that add (or subtract) value” [2]. For example, Mercedes-Benz’s brand equity is intimately linked to high levels of quality. In contrast, the brand equity of the US Department of Veterans Affairs health system has diminished significantly because of poor perceived quality secondary to the process metric of wait times for appointments. We all want a Mercedes hospital. A process metric would tell us that all the bolts are in place, but is it a quality product? As a consumer, you don’t want to take a hospital for a test drive. As an employee or private practice radiologist, you want your hospital to grow and thrive.

To get to true quality, we need to reflect internally toward the people who are in the best position to judge quality at their institutions, the staff members who work there. Our federal Agency for Healthcare Research and Quality is already doing that with its annual Patient Safety Culture Report. This report allows hospitals to poll their staff members and benchmark those results against national data. Highlights of the 2014 report include the fact that only 44% of staff members feel that nonpunitive responses to errors occur at their institutions, and only 33% of respondents grade their departments as “excellent” [3]. This is valuable information, but the survey to produce this report is long and complicated and is only performed once a year.

A better approach might be to ask your staff, “How likely is it that you would recommend your hospital (or department) to a friend or colleague?” This is one simple question, easily repeated on a quarterly or monthly basis, with rapid feedback. This question is already being asked in the business world as a measure of customer loyalty. If we were to similarly poll hospital staff members, we would get a pretty good surrogate for true quality. After all, a hospital might look wonderful on all the Medicare and Leapfrog metrics, but would you take your child there for an appendectomy?

When using a 10-point scale, one can take the number of promoters (scores of 9 and 10) and divide by the number of detractors (scores of 6 and below) to calculate a “net promoter” score. Companies such as Enterprise have learned that this net promoter score is directly related to economic growth. Many companies average scores of only 16%, but companies such as eBay, Amazon, and USAA generate scores of 75% or greater. This score is simple to produce and easy to repeat frequently. Often this score is directly tied to promotions within a company [4].

The use of such a measure, with the goal of improving true quality care, would also relate to retention of quality staff members within a hospital. A physician or nurse who values quality would benefit from working at an institution that demonstrates this core value. It is significantly cheaper to retain an employee or partner than to hire a new one. Health care systems should be measuring quality on a prospective rolling basis to keep these quality employees happy.

Furthermore, health care systems are some of the largest employers in their communities. If employees are unsatisfied with quality at their institution, negative impressions will spread quickly through the community. A system’s net promoter score and subsequent growth will suffer before a single patient satisfaction score can be calculated.

If true quality within an imaging department were to be tracked, components feeding into the net promoter score could be discussed and acted upon. A low score might motivate hospital administrators to address issues of inappropriate utilization, excessive radiation, and image quality. These are issues that are currently poorly quantified, seldom reported, and too easily dismissed by hospital administration. In an ACO environment, utilization, costs, and true quality become locked together and impossible to ignore. A growing ACO could create a positive feedback system of quality, costs, and utilization. The value equation, whereby value equals quality outcomes divided by cost, has the potential to increase exponentially.

The medical community would benefit from a new definition of disruption similar to that appreciated in the business world. Disruptive innovation is lauded, not penalized. It creates new value, eventually displacing an earlier technology [5]. A true quality measure would automatically incorporate any new issue or technology. It has foresight and is flexible. Current metrics, such as length of stay or readmission rate, would become obsolete if a new measure of true quality were developed. Collectively we need to reenvision how we measure quality.


  1. The Lazoritz Group. Available at: Accessed December 2, 2014.
  2. Peter, J.P. and Donnelly, J.H. A preface to marketing management. 14th ed. McGraw-Hill, New York; 2015
  3. Agency for Healthcare Research and Quality. 2014 user comparative database report. Available at: Accessed November 2, 2014.
  4. Reichheld FF. The one number you need to grow. Harvard Bus Rev. December 2003. Available at: Accessed November 22, 2014.
  5. Disruptive innovation. Available at: Accessed November 2, 2014.

About the Author

This article was originally published in the Journal of the American College of Radiology - Volume 12, Issue 7, Pages 696-697