Cultural Barriers to Quality

David B. Nash, M.D., M.B.A.
Disclosures		Relationship: Yes Other: Board Member of Itrax and Informedix

David B. Nash, MD, MBA, is the Dr. Raymond C. and Doris N. Grandon professor of health policy, and chairman, Department of Health Policy at Jefferson Medical College. Here, he discusses the main cultural barriers to quality in medical practice and how they can be overcome.

While physicians are well-trained in the science of medicine and have the skills to care for individual patients, says Dr. Nash, they could improve their performance with a better understanding of quality measurement. He believes that the cultural barriers to quality improvement can be overcome by a better understanding of the systemness of care. In other words, to move from "Who created the error?" to "What allowed it to happen?"

By understanding systems of practice, the author contends, we can close the gap between prevailing practice and evidence-based approaches. This involves collecting and analyzing data, working collaboratively with managers and patients, and learning from one's mistakes. In cultural terms, he says, we need to get away from "I" to "we" since physicians know little about their own performance relative to their peers ... and to make the cultural shift to support measurement of clinical, economic, and human outcomes.

It is this focus on the individual rather than on the complexities of the system which ignores the fact that 85% of the time medical error are due to process failure, and these errors need to be translated into the educational process. Other cultural barriers to quality in medical practice include the hierarchical nature of medical training, the inability of experts to admit that they are learners, and a slavish devotion to professional autonomy.

Overcoming the cultural barriers includes a better understanding of the systemness of practice and the ability to strive for Six Sigma Quality in measuring and improving the quality of medical care. This last forms a fascinating conclusion to Dr. Nash's lecture and has to do with a formula for comparing the likelihood of adverse events in, say, the airline industry with such events in hospital and patient care. This is effectively illustrated to bring home the point that much work has yet to be done in reducing medical error.