Quality Assurance and Peer Review are usually pretty dry and boring subjects, but these are very important functions and clearly need guiding principles along with a good process and operation. One of the beacons of how our peer review process is conducted has been firm and longstanding and can best be described as the “Mother Test”.
What is the Mother Test? It’s a new term to me. By way of background, our peer review program and process has been guided by being firmly both patient centered and physician centered. The patient centered aspect of this is fundamental and unwavering. As we review how we care for our patients, we use our own expectations as recipients of care as an absolute reference. We ask the following question in all cases: is the care provided in Catholic Health unequivocally what you or your family member would want if you or they were the patient? If the answer is yes, then pretty much the care issues are clear and the issue is closed. When at times the answer is no, then there is opportunity for improvement – whether that be an individual or systematic process. Either way, we always want our patients to be treated the same way we want to be treated if we are or were receiving care.
Recently at a meeting at Sisters Hospital, Dr. Khalid Qazi referred to this concept and evaluative reference as the Mother Test. He indicated that when training residents he always told that you should take always care for your patients the way you would want your mother to be cared for. This was a nice encapsulated reminder of exactly what our focus on superior quality is all about. I’m now committed to calling this the Mother test, courtesy of Dr. Qazi.
However, during the discussion at that same meeting that followed his comments, there was a physician who expressed a unique interpretation of the Mother Test. He indicated that if his mother was the patient her length of stay would be very long because he would want her to have more and more testing, and therefore the Mother Test results in prolonged stays and over-testing. In his view, more testing is better care and it is the quantity of the care that is both what individuals prefer, and what physicians should deliver – this is best care. Perhaps some of you agree with him.
Perhaps not, because there is a very different interpretation of what is the best care now. Most physicians as well as most (but not all) patients now appreciate that is the quality of care, not the quantity of care, that is the driving force behind what is “best” – the Mother Test measuring stick.
One example was discussed that we see every day, with patients who present with syncope. We know that a precise history, an EKG, and examination are the only evaluations that are needed on all patients with syncope. After that, there are very selected testing protocols that all national guidelines recommend, and most of the testing that we commonly see in syncope patients is unnecessary. Based on those guidelines, only selected patients should be tested with such extravagances as EEG, echocardiograms, CT scans, labs, stress tests, telemetry monitoring, consultations and other costly and cumbersome evaluations that are incompatible with good care according the guidelines we have all reviewed. When these complex resources are consumed on our syncope patients who do not need them, the hospital bears the costs as does the medical staff with numerous personnel, resources and beds that are unavailable for the patients who may really need them because we are tying up our these services with outlier practices that are not based on either evidence or guidelines.
If you take the quantitative approach, then you would want every possible test performed for your hypothetical mother and her hypothetical syncope. But what about her, not the suffering of our system and our quality measures? Let’s assume she clinically has vasovagal syncope and does not have any indicated guideline-based complex testing – like many of our syncope patients. If she now stays a day or few in the hospital to have her unnecessary EEG (among other tests likely added to her dance card), and then has a false positive test (like one of my patients just did), what about her outcomes? Does she now get good and better care? You know what really comes next – neurology consult, extra testing, fear and indecision, primary care physician now dealing with a confused and indeterminate picture, confusion about driving, and a real mess – without counting the possible effects of any fall she may have in the middle of the night after staying awake from all the interruptions and noises on the floor! And heaven forbid if one or several potentially toxic medications are started “just to be safe”. Sad, but we have all seen just this happen.
Quantity or quality – which one really is the Mother Test standard?
We now officially use the term “The Mother Test” as our guiding light for looking at quality. More importantly this is an opportunity to differentiate quality from quantity. We as a system can and always will stand for quality of care. Quality of care is no longer the same as quantity of care, and that is the direction we will proceed in together going forward. Times have changed, and we need to move forward – quality wins.
Edward Stehlik, MD, MACP
CH Chairman of Medicine
