Possible Unintended Negative Consequences Of Quality Improvement (QI) Goals

   This is an interesting qualitative “ethnographic” observational study of intraprofessional relationships between ER and general internal medicine (GIM) physicians in a major Canadian hospital, supplemented by ad hoc and scheduled interviews with faculty, residents, and nurses.  An institutional mandate to decrease patient time in the ER before admission or release (publicly reported data) was imposed two years before the study started.  After analyzing their data, the researchers felt that this mandate had potentially engendered negative consequences on: trainee education, ER-GIM physician relationships, interprofessional relationships with nursing, and truly patient-centered care.  Participants perceived that the pressure to make admissions decisions quickly led to less emphasis on diagnostic thinking with trainees, and a greater tendency to admit frail elderly patients with “failure to cope” (US physicians, read “failure to thrive”) who may not have really needed admission to the hospital in the opinion of the GIM teams.  Also, there was resentment of a new nursing leadership role which, in the authors’ words, does not exist “to provide better patient care but, rather … reinforces the hidden curriculum of efficiency.”  A weakness of the study is that there is no corresponding data from before the ER time mandate.  Certainly, negative ER-GIM relationships and negative views of certain high-need patient populations have existed before our current intensive focus on QI metrics. — Laura Willett, MD

Webster F, Rice K, Dainty KN, Zwarenstein M, Durant S, Kuper A. Failure to Cope: The Hidden Curriculum of Emergency Department Wait Times and the Implications for Clinical Training. Acad Med. 2014 Sep 30.

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