John Short - Christchurch Women’s Hospital

The Quality Formula

John Short

Obstetrician and Gynaecologist

Christchurch

• The formula

• Discuss components

• Present relevant data

• Explore expectations

• Propose challenges and pitfalls

About me

About me

• British

• O&G

• NZ 10 years

• Gynaecological surgery

Accident Compensation Corporation

• Crown Entity

• Accident insurance

• State levies

• No Fault

• Treatment Injury

Medical Indemnity

• $1800 pa

The Health and Disability Commissioner

• The Health And Disability Commissioner is a New Zealand Crown Entity responsible for promoting and protecting the rights of health and disability consumers (*), and facilitating the fair, simple, speedy, and efficient resolution of complaints.

The Health and Disability Commissioner

• Investigates

• Recommends

• Refers for disciplinary proceedings

• Refers to the medical council

• “First do no harm”

• “First don’t get sued”

• “First don’t get referred to the regulatory authorities”

The Quality Formula

•Satisfaction

The Quality Formula

•Satisfaction = Outcome

The Quality Formula

•Satisfaction = Outcome - Expectation

The Quality Formula

•Satisfaction = Outcome - Expectation

• Satisfaction drives complaints, litigation etc

• Why not just lower expectations?

• High expectations encourage good outcomes

• We should aim to meet expectations

• We need to understand expectations

• The aim is not to lower expectations but to encourage realistic expectations

Google results

• Psychology

• Marketing

• Hospitality

• Weight loss industry

Google results

• Expectancy theory

• Expectancy disconfirmation

• Expectancy violation

Google results

• Journal of business research

• Organizational Behaviour and Human Decision Processes

•Which field of medicine has studied this the most?

Satisfaction

“the problem with satisfied patients”

• Higher healthcare and prescription costs

• More likely to be hospitalized

• More likely to die within 4 years

• Patients are frequently very satisfied with hospitals that have below average outcomes

“the problem with satisfied patients”

• Treating patients as consumers

• The customer is always right

• Focusing on what patients want may mean they get less of what they need

• Put pressure on the system to do what it can’t instead of what it should

Outcome

• The result of treatment

Outcome

• Multiple factors

Outcome

• Skill, training, expertise

• Teamwork

• Systems, processes, culture

• Standards of care *

• The patient

OUTCOME

EFFORT

• Outcome is a constant

Expectation

• Anticipated result of treatment

Expectation

• Anticipated result of treatment

• Anticipated experience / process of care

Patient D

• Laparosocopic hysterectomy and excision endometriosis

• Private hospital

• Pelvic pain ?endometriosis ?adenomyosis

• 1 week later significant haemorrhage

• Public hospital

• Further surgery required

Patient D

• Indication for hysterectomy debatable

• Patient couldn’t afford private care

• Blood loss exagerated

Patient D

• Complained about care in Public hospital

• Nursing care

• Delays for tests

• Delay in arranging surgery

• Plus unresolved issues from 1 year prior, with one specialist in particular

• However very satisfied with private specialist

Expectations

• Specific to ‘treatment’ (test / consultation / birth)

• General to care

Expectations

• Specific to ‘treatment’ (test / consultation / birth)

• General to care

HDC

•Commonest services complained about:

• Mental Health

• Emergency Dept

• Maternity

What is the next commonest service to be complained about?

What is the next commonest service to be complained about?

• Orthopaedics

Commonest reasons for complaint

• Misdiagnosis

• Inadequate treatment

• Unexpected treatment outcome

Commonest reasons for complaint

• Misdiagnosis

• Inadequate treatment

• Unexpected treatment outcome

Other reasons

• Disrespectful manner/attitude

• Poor communication

• Inappropriate comments

• Cultural issues

• Inadequate information

• Professional conduct

General expectations- Code of Rights

General expectations- Code of Rights

• Treated with respect

• Dignity and independence

• Services of an appropriate standard * (credentials)

• Effective communication

• To be fully informed / informed choice and consent

General expectations- other

• Professionalism

• Compassion / Empathy / Humanity

• Attention

• To be thorough

• Certainty

Challenges and Pitfalls

• Health literacy

• The ‘patient care paradox’

• The ‘pygmalion’ phenomenon

• Expectation violation

• Perception vs reality

literacy

• 46% of Australian women aged 15-74 have a literacy level of 2 or less

• Good health literacy

• Bad health literacy

• Pseudo-literacy


• Health literacy





The consumer satisfaction paradox

• Intervention wins every time


• Health literacy






• Health literacy





• Anchoring bias


• Health literacy





• The difficult patient

• Standards of care

• Supervision of junior doctors

• patient introspection

• The ‘apology paradox’

• The family

• The spectre of uncertainty

• How to deal with the patient you don’t like?

• The difficult patient

• Standards of care

• Supervision of junior doctors

• patient introspection

• The ‘apology paradox’

• The family

• The spectre of uncertainty

• “What our profession needs is wise doctors who understand shades of grey, not geeks who think in black and white”

• “What our profession needs is patients who understand shades of grey, not geeks who think in black and white”

• “What our profession needs is patients (and families) and lawyers and regulators and managers/leaders and politicians who understand shades of grey, not geeks who think in black and white”

Summary

• Satisfied patients don’t complain

• Outcomes are very important

• Don’t forget Expectations

• The formula can’t be cheated

Law

John Short - Christchurch Women’s Hospital