The Big “Picture” of Health Care Quality in the U.S.

Metaphorically Speaking: Health Care Quality and Puzzles

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I view health care quality in the United States like a 1000-piece jigsaw puzzle of a beautiful, intricate, European seaside landscape. Fully constructed, a 1000-piece puzzle picture offers a breathtakingly beautiful scene that is therapeutic in a sense and possesses deep symbolic meaning within it. Each one of the thousand puzzle pieces don’t by themselves tell us much.  Yet each piece plays an important role in the picture’s whole. The absence of any piece matters. I would venture to say that all of us have tried to force puzzle pieces together that look like they should fit, but don’t’. We quickly learned that with trying to put together a complex puzzle, there are barriers, constraints and opportunities on how to solve them given the creative design, structural order, and practical realities in play.

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Health care quality in the United States is very much like a 1000-piece puzzle. Health care quality is, indeed, a complex mosaic – with many barriers, constraints, hard realities, and opportunities. Many things (i.e., pieces) need to fit together for the health care quality “puzzle picture” to be complete.  Indeed, many factors influence the ability to efficiently bring the pieces together to make a collective whole.

What is the Meaning of Health Care Quality?

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Broadly speaking, quality of health care encompasses experiences of care for patients, families, and caregivers, the culture of care, and structure, processes and outcomes of care. Within each of these broad areas, however, many system, organizational, scientific, clinical, and cultural intricacies related to health care quality come into play in determining what the final puzzle picture looks like.  

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What does health care quality mean for consumers?

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From health care consumers’ perspectives, health care quality is reflected in everyday life examples.

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• The care helping manage the pregnancy of a 25-year old, healthy women and the birth of her child
• The care for a 43-year old women through a high-risk pregnancy to produce a good outcome
• The means by which care is managed for a 13-year old, obese, pre-diabetic boy from a rural community in Maine
• How poorly managed bipolar disorder for a 40-year old professional male is supported in care to return to a place of high functioning
• The multifaceted medical and social supports needed for high quality management of a 35-year old woman living with schizophrenia and diabetes that is intermittently homeless
• How an 83-year old man in generally good health who fell at home and broke his leg receives and is managed through rehabilitative care to get back to full functioning

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Critical other aspects of health care quality that are embedded in each of the examples above and the millions of examples seen in health care in the U.S. every day are things like (1) challenges with the levels of transparency in healthcare, (2) experiences of care people receive, and (3) the culture of care that shapes the experiences. We all know from each of our own experiences the scores of real-life examples where things do not go the way that they should, and they happen every day.

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Here are several example scenarios:

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Scenario #1

A 60 year-old female patient received a referral for a cardiothoracic surgeon in a noted hospital from her cardiologist. The patient and her spouse want to know about the quality of the cardiothoracic surgeon, but do not know where to turn for this information.

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Scenario #2

A generally healthy 85 year-old man suffered from a series of recent falls. He fortunately was not injured. He thinks something is wrong that is causing him to fall. His wife agrees. The doctor, however, tells them that people his age periodically fall because balance is worsened in advanced age. The patient and his wife convey that they think something is wrong. The doctor does not listen to them or take them seriously. The doctor informs the patient and his wife that he should be careful to hold onto railings and take appropriate precautions in areas requiring good balance. The doctor does not order any tests and does not think a referral to a specialist is warranted.

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Scenario #3

A 70 year-old male patient is accompanied by his adult daughter to the emergency room in the evening because he has extreme pain from passing blood clots when he urinates. The ER doctor decides the patient needs to be catheterized to pass the blood clots; so does the procedure. After a period of time, the patient’s daughter, who is a nurse, thinks the catheter is not inserted properly. The daughter, who doesn’t state that she is a nurse, mentions this to the staff nurse, but the nurse insists with a haughty attitude that it is in properly and dismisses the daughter’s concern. The daughter doesn’t push the situation. The next day, the attending physician assigned to the patient sees immediately that the catheter is not   inserted properly. She makes the adjustment to properly insert the catheter, but permanent damage was done.

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Scenario #4

A 25 year-old, morbidly obese, pre-diabetic male from rural Maine is seen by his primary care physician. He is told that he must begin losing weight, eating healthier, and exercising several times weekly. He shares with the doctor that there are no grocery stores or markets with health food options near him and that he couldn’t afford the healthier food choices if there were. He also shared that his feet and knees hurt him when he tries to walk or cycle and doesn’t have access to a pool, so exercise isn’t an option. The physician informs him to get creative and use his determination to eat healthier and exercise, and then gets quickly to his next patient.

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These scenarios represent a few of the many that happen in real life. Thus, in the broader picture of health care quality in the U.S., the culture of care (in addition to the quality and processes of care) must also receive its due attention, because the two are highly interdependent. The Health Care Quality Insights Blog articles will talk about both of these areas.

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