Response from Feature Authors

Abstract

We appreciate the thoughtful commentaries on our article. Several of our ideas generated expressions of agreement, suggesting that approaches to quality are achieving a certain level of consensus. In fact, we would suggest that differences, where present, are in tone and accent rather than in theory. Nevertheless, some of our comments do bear clarification. In his commentary, Robert Lloyd expressed concern that we place greater emphasis on outcomes than processes. He aptly cites Donabediaris (1980, 1982) framework for quality assessment in healthcare, which indicates that outcomes are the result of structures and processes. Health systems, he writes, that focus on outcomes without attending to processes will be frustrated. We did not intend to minimize or devalue process measures. Most of our quality initiatives at Parkland rely heavily on the use of such measures, and we agree with the general supposition of most pay-for-performance theories that if processes are executed correctly, the outcomes are generally more desirable. Our goal was to inject some caution into the rush to embrace process measures in isolation. For any organization that is focused on population health, as we are, strict attention to narrow clinical processes may lead to little success. We believe the social and economic determinants of health can overwhelm even the best clinical engineering. In the complex setting of a safety net hospital, outcome measures allow us to keep our eye on the ball, in this case the larger forces that powerfully affect a patient's health. In our view, the selection of outcome measures dictates everything else, including what structures, processes, and most importantly, cultural, linguistic, educational, and economic contexts must be focused upon (Coyle 2000; Shojania and Grimshaw 2005). In this sense, we would expand upon Lloyd's statement and suggest that health systems that consider structures and processes without first properly considering outcomes, and all of the associated antecedents, will be doubly frustrated. For example, it has been our experience that public systems, such as health and education, are often compartmentalized, and there is little interaction across sectors despite tremendous overlap in needs and orientation. Minor failures in one sector may obviate excellent processes in another. Considering outcomes forces otherwise disparate public sectors to work together to manage the in-between (Boumbulian, Pickens, and Anderson 2004). At Parkland we have tried to migrate upstream in this way, and we are always searching for new programs that consider the influence of education, transportation, housing, and crime and fire protections on clinical outcomes. The CHIMES program, which we detail in the article, is a major organizational effort in this direction. We do not dispute Lloyd's contention that within the applied science of quality improvement many exciting and rigorous techniques do exist. Our point was to indicate that most quality improvement interventions have not yet used these methods and suffer from flaws that limit reproducibility. We are not alone in this view (Shojania and Grimshaw 2005; Shortell, Bennett, and Byck 1998). Furthermore, if improvement projects are not adequately designed, the wrong conclusions will be drawn. …