Chiropractors have been bombarded with articles about "quality of care" issues over the past few years. To an ever increasing degree, the profession is being asked to document the clinical improvements of patients under our care. Assessing patient "outcomes" can be done in a variety of ways, using a variety of instruments. Examples might range from a simple self assessment of symptomatic improvement (visual analog scales) or various surveys with demonstrated reliability such as Roland-Morris, Oswestry, etc. For doctors who prefer to assess outcomes in terms of function, the focus might be on objectively measurable parameters such as Range of Motion or strength/endurance testing. Those of us with an interest in structural rehabilitation/correction might focus on demonstrated improvement in patient posture as objectively evaluated by visual or radiographic analysis.
This forced movement of the profession toward more objective analysis (and ultimately justification) of what we do for out patients is ultimately a good thing I think. And as much as I dislike the process at times, I have to admit it's a bit presumptuous to expect third party payers to just endlessly shell out money without some assurance their insured parties (our patients) are receiving real and tangible benefits. Accordingly, I wanted to use this issue to voice a few thoughts on improving the quality of our patient outcomes. Along the way, I want to share a few thoughts about the subject of "quality" in general as it relates to our daily practice.
Mark R Payne DC
We talk a lot about "quality" in chiropractic. Terms like "Quality of Care", "Quality of Life", "Quality of Motion" are common. But ask a dozen chiropractors to define the term "quality" itself and you'll likely get a dozen answers. The term "quality' it turns out, may mean a lot of different things depending on what is being discussed. To complicate matters further, definitions vary wildly depending on which expert is doing the defining. Sometimes we define quality in rather ephemeral terms. For instance, when picking our political leaders or used car salesmen, we may be concerned with "quality" of character. (Okay, maybe not so much our politicians but definitely our used car salesmen) At other times, we may measure "quality' more objectively. An expert in the hospitality business may measure quality using customer satisfaction surveys while an expert in manufacturing may define quality in terms of how closely the end product conforms to the original design. Your own patients will likely define the "quality" of your services in very subjective terms, i.e. relief of pain or other subjective symptoms. Their insurance company however, is more likely to define "quality" more objectively in terms such as cost, length of disability, likelihood of recurrence, etc.
Doctor #1: I have a friend who in many ways is a great doctor. He's a fabulous adjuster, is really gifted with his hands, has a wonderful and caring demeanor, always focused on the patient before him, and is totally disciplined in the operations aspects of his office. His office is incredibly busy and efficient. Each patient encounter lasts only a couple of minutes and yet his patients absolutely love him. My friend isn't very big on "objective" or "technical" stuff. Although he takes radiographs on the initial visit, he never bothers to make any measurements, saying instead, "I know what's normal/abnormal when I see it." Post radiographs? Forget about it! (After all, the spine must be corrected if the patient feels better...right?) He defines a high "quality" chiropractic office as one which "does the most good for the most people". He assesses the quality of his care by how many patients are using his services and how many new patients are being generated from the refer
rals of satisfied patients.
Doctor #2: Conversely, I have another friend with a small, slow paced practice who is also a great chiropractor in many ways. He is very technically oriented, meticulously measures every radiograph, and dwells on every detail. Truthfully, he's probably much more interested in the details of a case than he is with the actual patient. He's also frequently gruff with his patients and his adjustments are rough as hell. Both he and his entire staff seem to be constantly having a bad day. To put it bluntly, his interpersonal skills just suck, but somehow his technical expertise, and attention seem to be sensed and appreciated by many of his patients sense. Ask this doctor about his definition of "quality" chiropractic care and you will get a very different sort of answer. Instead of some vague, "touchy feely" impression, you'll get hard, objective, facts. This doctor can tell you exactly where the patient's spinal structure was when he started and exactly how it changed during treatment. He can tell you how closely the patient's pre and post care postures conform to a precise mathematical model of "normal" or "ideal" structure or posture. He uses proven tools such as Roland Morris, Oswestry and Visual Analog Scales to document patient progress as well as other recognized indicators of spinal function such as Range of Motion.
Obviously, both doctors use widely differing standards in deciding whether or not their office is delivering "quality" chiropractic care. Doctor # 1 evaluates quality of care only in terms of patient satisfaction (how many people use his office, refer their friends and families, etc.) Doctor # 2 evaluates quality of care only in terms of his clinical outcomes. Arguing about who's right or wrong would take us away from a much more important point. Keeping data in an office uses up resources of time, money, and energy. So it's important to be sure we conserve our resources by only measuring and tracking those data which are: 1) truly important and 2) pertinent to what we are hoping to measure.
Doctor # 1 makes a classic mistake by looking at data relevant to one area (the business side of his practice i.e. patient volume, new patients, etc) and then attempts to extrapolate the results to a completely different subject. Basically he assumes that a busy office full of satisfied patients is proof enough that his brand of chiropractic represents a high quality of care. While satisfied patients are certainly one aspect of a well run office, there can also be many other reasons none of which have anything to do with the quality of care rendered. Maybe the front desk person has a great smile. (She does.) Maybe the payment plans represent a great bargain. (They do.) Or maybe (as in my own case) the doctor is just wonderfully witty and handsome with a certain irresistible boyish charm. Yeah maybe. At any rate, I think it's fair to say Doctor # 1 could probably do a better job of assessing his patient outcomes if he paid just a bit more attention to a few technical details.
Doctor # 2 ,on the other hand, focuses only on clinical outcomes and then worries about an appointment book that is never full. Doctor # 2 makes a classic blunder as well by assuming that if he does a good job clinically, it will automatically translate into a successful practice. (Wrong!) Truthfully, he could learn a few things from Doctor# 1. Instead of being so technically focused on actual patient outcomes, perhaps he might dwell a bit more on improving the patient experience in his office, on improving patient retention, and stimulating referrals. Maybe he and his receptionist could even work on their smiling skills a bit. Sure he does a great job of documenting treatment outcomes, but there's a lot more to practice than just getting a spine to change and an empty waiting room isn't helping anyone at all.
The secret it would seem is finding that happy balance. In reality, almost all of us collect data in some form or fashion anyway. The question is whether or not we have given thought to our overall strategy of doing so. When considering what data you really need to track you might want to consider: a) exactly what information do I need in order to improve both my business and my quality of care, b) how do I collect accurate and relevant information with minimum cost and effort, and c) what information is likely to be needed by third parties with a legitimate interest in quality of care issues.
Sure, we can argue about exactly WHAT chiropractors should be tracking and measuring, but the inescapable fact is we all need to be focused constantly on measuring the efficacy of what we do. Without real numbers, there's just no way for chiropractors, their patients, or those nice folks with all the money at the insurance company to have anything more than the vaguest of notions of what is really happening. Quality doesn't just happen whether you are talking about manufacturing a high quality car, or turning out healthier patients. And the one thing almost every expert on quality will tell you is that... "If you can't measure it, you can't manage it."
This failure to measure and manage is understandably impacting our relationship with third party insurers. Third party payers have a legitimate need to know among other things how much treatment will cost, how long it is expected to take, and how much real benefit their insured can expect to receive for the money spent. This is frustrating for many doctors because we often don't know the answers ourselves and we never will until we start keeping real records and analyzing the data. There is a persistent reluctance in the profession toward keeping accurate records, much less actually quantifying our outcomes. Until this attitude changes, we are likely to face continued headwinds in our third party relations. (And NO, I'm not naïve enough to think that just keeping better records will solve all our insurance problems.)
Look, it's no secret I have a strong bias toward structure based chiropractic and one reason is that it allows me to readily measure my treatment outcomes. I certainly understand and respect that many of you prefer other methods, but regardless of how you practice, we all need to focus on collecting, and quantifying the results of our care. Ultimately, the long term survival of our profession is likely to depend on chiropractors being able to document and communicate the efficacy of what we do. It all starts with clear cut decisions about how we personally choose to define and measure "quality" in our offices.
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