Quality Measurement and the Risk of Yin Without Yang

You can’t manage what you don’t measure.” This well-worn business axiom has been embraced by the healthcare quality movement, a trend this is healthy and long past due. But it comes with a risk:  
Yin without Yang. Yin Yang
What do I mean? With the (still scanty) evidence that tight glucose control improves the outcomes of med-surg (as opposed to surgical ICU) patients has come pressure to keep the average serum glucose level below a certain level, say 180 mg/dL. The Joint Commission checks that nurses assess patient pain control at virtually every encounter. And a commonly used “trigger tool” for medication errors tracks the use of Vitamin K or Fresh Frozen Plasma as signals that patients were anticoagulated a bit too enthusiastically.

This is terrific – after all, who wouldn’t want their patients to have controlled blood sugars, to be free of pain, and to not have blood oozing from their pores. But the risk of these unidimensional measures is that they apply strong pressure to control only one half of the quality equation. By doing so, the measures nearly guarantee “unexpected consequences” (unexpected only if you’re asleep, really) to push too hard on only one end of the see-saw.

We should promote measures that reflect the Yin and Yang of clinical care. What might such measures look like? How about measuring the quality of hospital glucose control by the percent of time patients spent with sugars between 70 and 180? Or assessing pain control by the number of patients with pain scores of 3 (out of 10) or less, with points lost for the use of Narcan or other evidence or respiratory depression? Anticoagulating a patient with warfarin? What if we defined quality by the percent of time that patients have INRs in the therapeutic (2-3) range. I’m at least as worried about the hospital or physician whose pulmonary embolism or DVT patients hang around with INRs of 1.5 – putting their patients at risk for more clot – as I am about those whose patients have INRs of 3-4.

We needed to start somewhere, and some unidimensional measures were reasonable first passes at quality. But as the quality measurement field matures, we’ll need to aim for a more holistic approach, one that rewards systems for getting it right, not just for not getting it wrong in one direction or another.


By the way, I’m baa-ack.  I just finished being on clinical service for four of the past six weeks – as I mentioned previously, it was great fun and tremendously rewarding, but my teams were really busy and my blogging had to take a back seat. In the coming weeks, I’ll be talking about resuscitating 90-year-olds with dementia or metastatic cancer, Google’s new foray into the world of healthcare, the mounting challenges of recruiting and retaining hospitalists, and more.

In other words, when I take a brief break from the blogosphere, you can assume it is not for a lack of blogosfodder. Thanks for hanging in there.


  1. menoalittle on March 3, 2008 at 12:42 am

    You present a provocative concept. As the profession hurriedly responds to guidance to measure so it can be scrutinized for quality (whatever that is), the art of medical care (comprised of judgment, compassion, understanding, and ambiguity management) is vanishing.  Is it not this art, in conjunction with detail management that actually makes a physician an effective diagnostician and healer?

    As physicians and nurses heavily weigh the seesaw on the side of  (i.e. more time with) health it devices, the patient is left up in the air wanting for attention and may not be safe way up there. Disempowered patients are safe and feel safe when they get attention.

    Likewise, the art of medicine requires being in front of a patient. As the profession moves to measure in order to manage, the most important measurement parameter may very well be how much time doctors and nurses are thoughtfully looking at the patient as compared to how much time they are mindlessly filling in health it device measurement grids or tediously working the keyboard to avoid the pitfalls of care altering CPOE devices.

  2. mgraban on March 7, 2008 at 2:06 am

    Bob – As the page you linked to points out, the quote there is actually a misquoting of Dr. Deming. That is not what he said and it is not what he meant.

    From the curiouscat.com page you linked to:

    “Deming realized that many important things, that must be managed, cannot be measured. Both those points are important. One, you can’t measure everything of importance to management. And two, you must still manage those important things.”

    There are many important things in healthcare that cannot be measured easily. These things still have to be managed. That is why Deming railed against having targets and goals. You need to focus on the process and you need leadership.

    It’s much easier (and more typical of western MBA management) to use targets, goals, incentives, and exhortations.

    I agree that healthcare quality must evolve — and relying less on measures (especially those that aren’t the right measures, those that antagonize good people, or those that can be “gamed”) might be a step in the right direction, actually.


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