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Medicare: New Directions in Quality Assurance PART V New Directions: A Patient Outcomes Orientation
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Medicare: New Directions in Quality Assurance This page in the original is blank.
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Medicare: New Directions in Quality Assurance New Directions: A Patient Outcomes Orientation Introduction Charles J. Fahey I would like to relate a personal experience and an underlying historical reality associated with it that have relevance for our efforts. Several times in the past few years, I have had the privilege to visit Monte Casino. Some of you are familiar with it, perhaps for no other reason than World War II. During the Italian campaign, the monastery became a symbol of resistance. What to do about it became the subject of contention among the allies. Although the presence of German troops on the slope on which the monastery was located was certain, it seemed they had refrained from entering the monastery or its immediate vicinity. However, its overarching presence became so much a symbol of the inability of the allied forces to move forward that it was decided to obliterate the abbey with intense air bombardment. Whether Germans were, in fact, inside the monastery is a moot point. However, following the destruction of the monastery, the rubble that remained became an even more formidable obstacle and was taken at a great loss of life. Scruples about destroying the monastery came not only from the potential loss of life (many local civilians had sought sanctuary with the monks) and the beauty of the buildings and contents but also because of its place in history. You see, it was here in the sixth century that St. Benedict founded Western monasticism. The approach to life of St. Benedict as articulated in his "rule" became a standard for virtually all communal religious life. At its heart was a commitment on the part of aspirants who wished to join this way of life to living in a spirit of poverty, chastity, and obedience with persons of like mind. When a period of training and testing were complete, the person stood before the community and made a public profession of his or her intent. This was known as making their profession. In the Middle Ages, the guilds took upon themselves some of the responsibility for what religious communities had done. Those that were particu-
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Medicare: New Directions in Quality Assurance larly involved in deeply human enterprises were known as professions, precisely because they had altruistic values of service to others about which they would hold themselves publicly accountable. Their service—although it meant a return, both psychological and pecuniary—also involved a commitment to competence, selflessness, and a concern for others. If ever there has been a word that has been corrupted it is "professional." Nevertheless, it continues to be an extraordinarily important word. This part of the conference proceedings addresses personal and corporate professionalism in the sense of personal and corporate virtue. There are really two things that we are about. First, how do we know what is good, and how do we make that knowledge relevant to people on both sides of the transaction—the helper and the helped? Second, how do we all behave better? It is interesting how much of what we are talking about involves behavior and values. In this effort we have faced a dilemma that plagues all of society. What is the appropriate role of external oversight and sanctions as contrasted with dependence on people to act virtuously? How do you protect the vulnerable without instituting oppressive structures that demoralize? By the same token, we have struggled with how to help people to be honest about their shortcomings without becoming unduly liable because of their honesty. How do we allow humility in our context? Humility is a very good word. How do we create an atmosphere in which we can be honest as individuals and as groups of people coming together to try to make good things happen? How do we help people to be virtuous? Laws and regulatory techniques have their limitations. Whether we are on the left or the right, the tendency is to use law to enforce on everybody else our particular view of what is the good. Yet two such diverse persons as John Courtney Murray, the distinguished Jesuit who was chiefly responsible for the Vatican II Decree On Religious Liberty, and Oliver Wendel Holmes held that American democracy is predicated upon our being a virtuous people. Laws and regulatory activity are important, but ultimately our surviving as a people will depend on how virtuous we are. Much of our effort has been to carve out a role for government that allows it to protect those who are vulnerable but at the same time encourages personal and corporate moral agency and virtue. Moving toward a world that enhances personal choice, decisionmaking, and responsibility calls for greater attention to patient outcomes, values, and preferences. The case for the "new direction" of a patient outcome orientation is made by committee member Albert Mulley, who is chief of the Division of General Internal Medicine at the Massachusetts General Hospital. The response is offered by John Wennberg, professor of epidemiology and community medicine at Dartmouth Medical College and pioneer of several critical areas of research in health services, effectiveness, and outcomes.
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