Published in: New York Times
Issue/Volume: July 29, 2008
Written by: Abigail Zuger, M.D.

7/29/2008 – There are more than 800,000 doctors in this country, more than two million nurses and several million other health care workers. Until recently no one really knew what any of them were up to. Hospital walls bulged with frenetic activity, but all the public saw were the happy successes and the occasional tragic complications.

Those days are pretty much over. From what has been called a perfect storm of disgruntled patients, legislators and medical professionals, the quality movement in health care has been born.

Thanks to its efforts, those hospital walls are slowly becoming transparent. Revealed is a world of tangled routines, many obsolescent, many downright stupid, that no one had carefully examined. The reformers are out to streamline the routines, retrain the workers and keep them permanently on display — an ant farm behind clear glass — to make sure things never get out of control again.

Their early work was invisible to the public, but even that is changing. Take, for example, the latest benchmark in transparency: on a Wednesday late last May, newspaper readers across the country could compare how local hospitals performed on two measurements of the quality of care, not by slogging through a news article but by scanning a large government-sponsored advertisement complete with graphs and a Web address ( for more details.

That is just the first installment of such data on display. Soon both hospitals and individual practitioners will be publicizing their own report cards. Insurers will be paying them for good grades, penalizing them for bad. Incentives to minimize errors, complications and inefficiency will mount. Health care will become perfectly safe, perfectly smooth, perfectly perfect.

How did this messianic movement arise and take root, and who are its prophets? These are the questions Charles Kenney valiantly tries to answer in what is the first large-scale history of the quality movement. [Webmaster’s note: Sorrel King is one of the people profiled in the book.]

Mr. Kenney, a former Boston Globe reporter and editor who is a consultant for a Massachusetts health insurance company, has set himself a giant assignment. While the book is not a success — an uncritical paean to his subjects, it reads like a corporate annual report — he provides a reasonably complete and up-to-date picture of the ambition and complexity of the enterprise.

Part of the problem is that he is trying to describe a target in motion, with roots almost as tangled as the chaos it seeks to eradicate. Poor-quality health care takes a variety of forms, each attracting a different set of crusaders.

Some have taken on the big blunders — errors of misdosed medication and operations on the wrong leg. Some have tackled “complications,” like catheter infections, that were once thought to be inevitable risks of hospitalization and now seem entirely preventable.

Some have focused on the smaller inefficiencies — little details with costly consequences, like medical records that disappear just when they are most needed and laboratory results that vanish into giant black holes.

Some aim to rearrange the physician-heavy hospital hierarchy so that all health care workers, and even family members, have the opportunity to call the shots in a patient’s care.

Still others focus on getting sick people correctly cared for: tight blood-sugar control for diabetics, regular Pap smears for women, flu shots for all.

Government and industry have been sources of inspiration for these goals. Experts from NASA to Toyota have tutored health quality gurus in the basics, like needing to prevent errors rather than punish them and respecting the right of any worker to stop the assembly line when a mistake threatens.

Mr. Kenney is scornfully dismissive of unnamed physician naysayers who point out that “human beings are not cars” and shy away from health quality control. It is these doctors’ “crust of hubris,” he argues, that prevents them from seeing the merits of new algorithms. Indeed, it is hard to imagine how any sane person could fail to leap on the quality bandwagon as presented here; it is all so self-evidently fabulous.

But readers should be aware that Mr. Kenney’s story ignores a wide array of questions that have some thoughtful members of the health care world a little troubled by the quality evangelism.

What does quality care mean, for instance, in cases of hopeless illness? When the outcome of care will not be good, how should good care be redefined? Suppose patients sabotage their own care, as so many unwittingly do. Who takes the blame?

And most important, what does it mean when science impudently undercuts accepted quality benchmarks? Only this past spring, for instance, two giant trials suggested that for some diabetics, tight blood-sugar control did nothing to safeguard them against some feared complications of diabetes and might actually endanger them.

Quality is a clear goal in product development, but in health it is still a shimmering intangible. All credit to the quality mavens; they are certainly fighting the good fight, and most of them deserve every laudatory adjective in Mr. Kenney’s thesaurus.

But fortunately for us all, most of them are smart enough to realize that human beings are not cars.