Drs. Goopman and Hartzman point out in the following article how process quality measures can lead to the wrong conclusions about physician performance. It is possble that this is true. If standards change or not enough data is available to make accurate conclusions about performance inappropriate conclusions could be drawn when comparing physician performance. When we have developed effective outcome measures using a statistically valid set of data we will be able to accurately compare physicians on what really matters.

It is true however that we must start somewhere and the process measures are what we have. Some are better than others such as A!-C(blood sugar control) levels and LDL(bad cholesterol) so if incentives are being used to change behavior let's use the best measures that are reflective of true outcomes that we have. Our stance is we should be incenting medical staffs to focus on improving care. We have found in Wisconsin that publishing performance information on physicians publicly is all it takes to get attention directed at the areas needing improvement. And we have seen dramatic improvement in process and outcome measures when the teams responsible for caring for these patients have compared their practice to better performers. This learning is what has driven change in their practices and improved A1-C rates, door to ballon times, and many other measures.

Beyond the transparency of performance (for improvement sake only) we have found at Thedacare that focusing clinicians activity on improving performance every day has led to dramamtic results. Cardiac mortality rates have fallen to STS (Society for Thoracic Surgery) benchmarks, A1-C rates are the best in the state and door to balloon time AVERAGES 37 minutes. These reults have not been acheived by the government dictating how we practice but by the use of a consistent improvement process derived from the Toyota Production System and applied to healthcare. The authors point out how shockingly sloppy processes like hand washing are in the hospital. There are many other shocking events that occur every day in hospitals and clinics. Without a consistent continuous improvement method and a culture of continuous improvement we can't improve them. If we are going to have carrots and sticks it should be centered on what improvements healthcare organizations and providers are making every day, month, and year.

Measuring and improving is how we are going to create better performance in healthcare not dictating and punishing.