Why High Quality does not mean High Cost
A veterinarian recently said to me, “Maybe we are trying to so hard for high quality that we are just pricing ourselves out of the market.” Indeed, there are statistics that show that the price of veterinary care is increasing faster than the consumer price index. However, is quality really rising in conjunction with cost? Does it actually cost more to provide quality care? I would argue that high quality care is not correlated with price or cost.
In 2009, Atul Gawande addressed this issue in a New Yorker article entitled The Cost Conundrum. At the time, one of the most expensive places in the country for health care happened to be a small town in Texas. However, on most of the Medicare metrics for quality, this small town actually scored worse than its neighbors. In contrast, in Rochester, Minnesota, where the Mayo Clinic dominates and is known for top quality care, Medicare spending per patient was actually in the lowest 15% of the country.
As I stated in previous blog posts on quality and safety, I define quality in veterinary medicine as safe, reliable, and effective healthcare that puts pets and their families first. We currently do not have outcome measures or metrics in which to truly evaluate veterinary quality. We need to develop quality metrics so we can measure what we do, establish baselines and find ways to continuously improve.
A starting point is STEEEP, six key metrics adapted from Crossing the Quality Chasm.
- SAFE – no harm to patients in hospitals
- TIMELY – ER care and test results should not be delayed
- EFFECTIVE – people need the right treatment for the right disease, with evidence-based recommendations put into practice quickly
- EFFICIENT – systems need to avoid duplication of testing and need to aim for the right diagnosis quickly
- EQUITABLE –all people no matter their class or race should be cared for equally
- PATIENT CENTERED, or for us, PET FAMILY CENTERED – the patient AND client’s needs should be always at the forefront
Let’s go through examples in each of these six areas to demonstrate how all veterinary hospitals can improve QUALITY with no additional COST:
Safety
As I mentioned in a previous blog, the use of a checklist in surgery has been shown to decrease post-operative complications in both human and in veterinary medicine. Checklists are FREE and increase quality.
In addition, studies in human medicine have shown that implementing a no distraction policy when nurses were making up medications can decrease the incidence of medication errors. Implementing this can be as simple as a no talking while someone has on a yellow sash.
Timely
Clients judge you by the time they spend waiting, especially in an emergency room. Some days, waits are inevitable. However, looking at client flow and staffing in our ER revealed that moving two nurse shifts by one hour would help match staff to caseload. No hours were added – they were simply aligned. Wait times were improved with no added cost. Where are your bottlenecks and can small changes help alleviate them?
Effective
Some studies in human medicine have shown that up to 50% of people may not receive care based on evidence-based guidelines. Part of the reason is that it is HARD to keep up with a constantly changing body of knowledge.
Some human hospitals are improving. Seattle Children’s Hospital has developed what they call “Pathways.”
These are recommended flow charts for care for specific diseases that doctors within the institution have agreed upon. These are kept updated by topic experts within Children’s hospital. The best part is that they are easily accessible from their EMR.
My previous hospital used agreed upon medical “pathways” that we updated as a team. They were extremely useful for our new ER veterinarians. I believe that the process of keeping a current, easily searchable, collaboratively created, group of recommended best practices and checklists improved the quality of care that our doctors provided. A study we did on urinary obstruction in cats showed that a change in hospital protocol reduced the re-obstruction rate.
Efficient
Patient care does not improve when we repeat tests unnecessarily or perform tests that will not change what we do. The times I have sadly had to repeat tests have been when I have had a critical pet transferred to me without records. We improve quality and decrease client costs when we do doctor to doctor phone transfers AND assure that complete records are sent quickly. Luckily in veterinary medicine, we are able to easily share records between primary care and emergency hospitals without HIPPA constraints.
Equitable
Our society is multicultural and if we want to expand who we serve, we must be sensitive and ready. I was so pleased when one of my employees who speaks Japanese was able to communicate with a hotel in Tokyo so we could reach an out-of-town owner whose dog was very sick. I was impressed with a hospital I know in Arizona that looks specifically for bilingual staff. When we can recognize our implicit bias and simply always present options A-C in medically appropriate order, we will provide the best care to the most families and will often be surprised at who says yes to option A.
Pet Family Centered
In our profession, we have both a pet and a family in every interaction. By recognizing and acknowledging the differences in that bond and in family circumstances, we provide compassionate quality care.
Many years ago, I had a 9-year old cat present to me for vomiting, diarrhea and severe lethargy. The cat was in shock and very dehydrated. With in-house emergency blood work and urinalysis, I diagnosed diabetic ketoacidosis. This is an expensive critical problem with initial treatment mortality of at least 20%. More importantly, diabetes is a life long disease that requires twice daily injections and ongoing veterinary involvement.
I spoke with the owner about the results. She told me she was in the military, about to be deployed for the next 3 years, and could not take the cat. She was also single with no family or friend that could take the cat. Together, we made the decision to say goodbye to her beloved pet. This was a very sad outcome but how much worse, if she had spent $2000-5000 in the ICU and then realized she couldn’t provide long term care? Instead, she had a diagnosis and someone to show empathy for hard decisions that sometimes we all have to make. It is crucial that we always talk about both short-term costs but also the full long term picture of care so that owners can make appropriate choices early for their pet and family.
By keeping STEEEP in mind when we think about quality care, we can begin to truly measure and define quality in veterinary medicine and help pet families make cost effective decisions. High quality does not have to mean high cost.