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Some Unintended Negative Consequences of Quality Targets

December 4, 2011

As the suits in the healthcare industry continue to try to change the healthcare system in their own MBA image, words such as targets and metrics are commonly used. A recent commentary from the BMJ reminds us of how sometimes when one process is improved another suffers.

Patients want quick access to their doctors, so the NHS decided to measure how often British GPs saw their patients within 48 hours of the request for a visit. What could go wrong?

  • At the same time this initiative was launched, the NHS also launched a series of reminder letters to patients with a chronic disease. Since most patients with one chronic disease have at least one more, they received “…gobbledygook reminder letters almost monthly. Also, all nursing time and much of the medical time was spent seeing patients for ‘reviews’ they had never requested.”
  • Therefore, appointments and computer systems began to clog up with pointless visits.
  • Intervals for these “reviews” had no evidence and were arbitrary.
  • This reduced the number of slots for patients with acute illness.
  • To meet the quick access target, practices stopped giving out appointments in advance and forced patients to call the practice each morning. This “telephone roulette” meant only the most persistent got appointments. If they couldn’t get through to call the practice, they didn’t count against the quick access target.

The net effect of this improvement was to actually limit access, but the measurements would tell a different story.

I actually have nothing against measurements and expectations, just metrics that are clueless about the complexity of primary care.


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