In this Question and Answer, HDC Board member Dr. Gerald Tevaarwerk provides his points of view on a number of related topics and why he believes that the real-life data gathered by the HDC is key in determining where to start serious discussions on where to reduce waste in the system.
About Dr. Gerald Tevaarwerk, Specialist Consultant in Endocrinology & Metabolism and Clinical Epidemiology
Having worked, taught and researched in three very different medical care systems has given Dr. Gerald Tevaarwerk insight in what is more likely to have physicians provide the best possible care in a cost-effective manner. He says he has come to realize that the profession needs a different business model in BC to improve the access to first rate medical care in an efficient manner. It can only be achieved through changing the conditions under which physicians work, providing them with more time to exercise their hard-earned skills, better resources and support and appropriate incentives to motivate a drive for continuous quality improvement.
Why is QI important for the average physician?
Continuous Quality Improvement (CQI) is important for the average physician because the very reason they entered the medical profession is to ‘repair that which is broken’ in as efficient a manner as possible. In the process we gain the approbation of colleagues, the gratitude of patients and fair economic reward.
How does having a QI lens help physicians to improve patient outcomes or does it?
To maintain CQI requires an ethos of lifelong learning. Having a QIlens provides a standard against which to measure whether the learning undertaken results in improved patient outcomes, provided the standard is evidence-based.
Why are you so passionate about this?
Most individuals have an innate striving to be very good at something, be it in their profession, a game, or a hobby. Several studies have shown time and again that individuals involved in cognitive tasks are strongly motivated to become better at it provided they already have reasonable economic rewards, are provided the opportunity and freedom to proceed as they consider best, and disincentives and barriers are minimized. As this is natural to professional individuals it is paramount that the conditions are provided to allow this to happen to the greatest extent, especially with increasingly fewer available resources.
Why should physicians care about CQI?
The main reasons physicians should care is that only in that manner will they experience the greatest personal professional satisfaction, a reward enhanced by knowing that one contributes to saving the planet while providing many individuals with improved qualities of life.
Who are the leaders in this field?
The “leaders” in the field are the many physicians who care about practicing the highest quality of medicine in the most efficient manner and teach that to their patients, colleagues and students, especially by example. On a broader scale there have been many attempts at formalizing CQI for physicians, the latest iteration of which is Choosing Wisely. Internationally, in my opinion the most outstanding proponent is Jack Wennberg at Dartmouth College of Medicine in Hanover, New Hampshire, with his many studies on variations in healthcare delivery. The late David Sackett also made huge contributions with his expansion of the concept of evidence-based medicine as first conceived by Archibald Cochrane.
What influenced your thinking in this area?
Having grown up in a war-torn country with scarce resources that had to be used in the most efficient manner gave one great satisfaction. The profligacy I subsequently observed in developed countries, described as “conspicuous consumption” by Thorstein Veblen in his Theory of the Leisure Class as early as 1899, reading the works of authors described under 5, and learning about the “invisible hand” in reading Adam Smith’s The Wealth of Nations (1776), matured and confirmed my early beliefs. Several of my teachers and mentors further reinforced those ideas.
What is different about the HDC approach – why will it appeal to physicians?
The Health Data Coalition approach differs from the usual CQIapproaches in that it was created and developed by physicians at the coalface, changes and approaches that reflect what is truly needed. As such, many physicians will recognize their own needs and ideas in the approach, making it more appealing to them.
What can we get from the HDC toolset we can’t get elsewhere?
The Health Data Coalition approach differs from the usual CQIattempts by measuring “what is” on a large scale, providing the data needed to define where we are going wrong and what we are doing right.
And why is what HDC collecting so important?
It is important in that it provides the opportunity to measure oneself against others and, in time, against evidence-based metrics that provide the best possible outcomes in the most efficient manner, thereby satisfying the ethos common to physicians, as set out in my responses above.
How will HDC help to inform system level planning and allocation of resources?
By identifying what actually happens over and over again in the offices of primary care physicians it provides the raw data essential to identifying what adds no value to patient outcomes, providing a means of getting at how to reduce the $6 billion spent needlessly every year in BC. It allows the development of approaches to reducing waste.
How will the HDC keep up with new measures/indicators and areas of interest and how do we make sure our measures are relevant and follow best standards?
To keep up with new measures/indicators the HDC must entice individual professionals to take an interest in what it does and recognize that this is a means to greatly improve the delivery of medical care. By studying what measures and indicators have been proven to be most useful locally and elsewhere in achieving that goal the HDC will have a continuous source of information needed to remain relevant.
What do you make of the statement: not everything needs to measured?
In my opinion everything should be measured. However, it is obviously important to identify where the greatest benefits may be achieved, starting with the “lowest hanging fruit”.
What’s your view of tying incentives?
Tying incentives and rewards to strategy execution is essential in achieving success. The lack of success of many previous CQIattempts has been due to the failure to do so. The important message here is to ensure that the incentives and rewards are appropriate, ones that provide the optimal conditions under which physicians carry out their many tasks. It is not about earning more money but to earn it differently, emphasizing the non-financial rewards of practicing medicine. To achieve this I believe we need a new business model, one based on what we do now as measured by the HDC in a manner that improves the quality and efficiency of providing medical care and in the process satisfies the Triple Aim Objectives.