Legal / Ethics

Ethics and the quality of care

Heaven knows the federal government, ably abetted by various organizations, publications, societies and the like is doing its best to improve healthcare quality through value-based purchasing, Hospital Consumer Assessment of Health Plans Survey, the Agency for Healthcare Research and Quality, the International Society for Quality in Healthcare, and the Healthcare Effectiveness Data and Information Set, not to mention various boards, roundtables, financial incentives (or disincentives), and quite literally thousands of other efforts.

We also pay a mind-bending amount of money for healthcare—recently and ably reported in scandalous detail in the March 4, 2013 issue of Time magazine. Nonetheless, the quality of healthcare services in the United States has been falling. “Not only do Americans live shorter lives than people in other wealthy nations, but they suffer more violent deaths compared to their peer countries,” says the 2013 report “U.S. Health in International Perspective: Shorter Lives, Poorer Health” from the Institute of Medicine. What could we have missed?

In their book When Smart People Work for Dumb Bosses, William and Kathleen Lundin state, “Look carefully and you will see only two routes to quality: smart and dumb. Smart occurs when people trust their leaders, want to learn, and are proud of what they do. Dumb is fraught with fear, lack of trust, and capped by poor leadership…”

Healthcare quality’s body of “common law” is set down by numerous agencies, from the official (like Medicaid) to quasi-official (like Centers for Medicare & Medicaid Service, The Joint Commission, and DNV Healthcare), to unofficial, but nevertheless influential (like professional associations, consumer organizations, and many others).

We measure our success in terms of survey scores. I have lived through the decline and rebirth of so many quality programs that I have lost track of them. To quote Lundin and Lundin, “If one quality program appears not to be working, switch to another. There are always others that appear on cue, almost miraculously, like desert wildflowers after the briefest of rainfalls. Every new program is a rebirth experience for management. Alas, the desert wildflowers droop, starved for water. The fine program takes the mind off the old one, and is again replaced.”

But what does quality look like to the people who are where “it” is supposed to be happening? That’s another question, indeed. As Lundin and Lundin say, “These are the parameters to keep in mind. Dumb leadership yields dumb, relatively useless information. Smart leadership generates worthwhile information. But how are quality assurance managers to know whether [they are getting]…smart or dumb information? They can’t because they are trapped within a closed universe.” The only way to find out is to understand what the universe is really like.


So what is the real universe like? Dysfunctional, money-driven organizations process useless information to satisfy the demands of inept, misguided, naive, insensitive, power-driven regulations, led by tradition-bound, arrogant, and self-important “leaders.” Many reasons explain why, including the glorification of the profit motive in healthcare delivery (why else all those financial incentives?) and the naive and unsupported belief that U.S. healthcare is the best in the world. And, because we are so sure no one before got it (care delivery, quality, and safety) right. Here are a few hard realities:

  • Most quality programs don’t work, but every new quality program is a rebirth experience for management.
  • Therefore, employees who actually deliver the service become immune to the quality program procession. If they do the right things, it’s independent of the programs.
  • Denying the weakness of your organization’s quality efforts will make you dumber, not smarter, and less fit for leadership.
  • Leadership must speak to both employees and customers. Otherwise all you get is hopelessness and contradictions.
  • Quality is in the hands of the “doer,” whether tending a machine, a group of students, or a group of patients. The meaning of quality in health care is the one-on-one: the “I do, you do, we do, someone gets better, or someone gets hurt.” In most hospitals most of the time, that means nurses do it (that is, deliver patient care) most of the time.

Those of us who were student nurses many years ago remember that our instructors used certain words that were intended to teach us how to be “good” nurses. The words were woven into basic nursing arts courses, professional adjustments, and clinical practicum. They were our value words, our moral primer back in the days before ethics courses. The primary words I refer to were courtesy, kindness, respect, accuracy, duty, loyalty, commitment, justice, honesty, diligence, compassion, and discipline.

Let us take for example, the age-old ethical norm (and foundation of the nurse’s notes) Honesty is not only the best policy, it’s the only policy. Honest and timely reporting had the moral support of countless nursing instructors, head nurses, and nursing supervisors. Not only did we report what happened, including any errors, we also reported any “near misses.” It was expected—and our consciences (not to mention our faculty) would have expelled us if we had failed to do so.

From there we moved into Principles and Practice of Nursing by Harmer and Henderson, first published in 1939 and reissued again and again until 1968, (our old-fashioned nursing “Bible”), learning what the nurse does for the patient (what he would do for himself unaided if he could), the importance of aseptic technique, our social role and proper professional deportment. We never doubted our intelligence (only the top 10% of high school graduates were permitted to enter a nursing program) or our ability to learn quickly. (We worked 40 hours a week, attended classes 20 hours, and had to study and socialize in what was left). We were indoctrinated and inspired by stories of Florence Nightingale, Clara Barton, Lillian Wald, Ann Breckinridge, and le Genevieve de Galard-Terrause: those nursing over-achievers who became great despite the odds. By the time we were ready to graduate, we had learned the words that spelled out the character of the ideal nurse and of us, nursing’s earnest apprentices.

At commencement exercises, the class valedictorian always reviewed the professional standards our honorable faculty had inculcated in us as they led us up the rocky road of Professional Achievement and Integrity, carrying the Nightingale lamp in their hands as a beacon to light our path through the darkness of illness and despair. We were never to forget—or fail to remember—the trust placed in us, the lives that depended on our judgment, or the responsibility we bore to promote our noble profession. These were the keys to success: hardly a source of envy for anyone and certainly not a source of high income. It was made clear to us in a thousand ways that the moral values that sustain the profession were not to be undermined in deed or even in thought. Whether we knew it or not, we shared a common vision. This vision, and the values that sustain it, led us to the pursuit of “quality” healthcare back in the day when U.S. healthcare was the world leader in its field. Our common vision was value-based rather than rule-based. And while less “measurable,” it produced immeasurably better results.

Leah Curtin is Executive Editor, Professional Outreach for American Nurse Today.

Selected references

Brill S. Why medical bills are killing us. Time. March 4, 2013:16-55.

Crosby P. The Quality Digest. April 1997;27.

Curtin L. Quality the old fashioned way. Nursing Management, Editorial, March 1994.

Lundin W, Lundin K. When Smart People Work for Dumb Bosses. New York: McGraw-Hill; 1998.

Peterson D, Hillkirk J. A Better Idea: Redefining the Way American Companies Work. New York: Houghton Mifflin; 1991

Woolf SH, Aron L. eds. U.S. Health in International Perspective: Shorter Lives, Poorer Health. 2013. The National Academies Press. http://sites.nationalacademies.org/DBASSE/CPOP/US_Health_in_International_Perspective/index.htm#.UUIxpY6ms5Q. Accessed March 12, 2013. Comparisons of mortality rates from a wide variety of countries can be accessed at http://sites.nationalacademies.org/DBASSE/CPOP/DBASSE_080393#deaths-from-all-causes.

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7 thoughts on “Ethics and the quality of care”

  1. Leah Curtin says:

    First,to DM: No,I don’t think my colleagues are arrogant etc.Now to the May 8 comment; I do not think quality is a ‘soft’. In fact I think it is the most substantive issue. If you don’t believe me, just look at the American Auto industry in Detroit MI. Why did they go under? Poor quality, so Americans bought (mostly) Japanese cars (good quality). It took bankruptcy and tax-payer bailouts to rescue them,and once again American cars are (mainly) good quality. America’s hospitals take heed!

  2. Anonymous says:

    Do you think that nurses’ focus on “quality” is another one of those ‘soft’ issues, like compassion and caring, that make nurses look unprofessional – not science or results oriented? I heard a speaker talk about how nursing’s focus on these ‘soft’ issues, on ‘virtue’ so to speak, undermines nurses credibility (and income) and evidence-based practitioners.

  3. Anonymous says:

    It isn’t possible to give good care when Administration cuts staffing so badly! In our rehab unit, all personnel were let go except one RN who was expected to give all patient care, deliver food trays, and even clean the unit…all this for patients fresh from acute care — 3 days post op for knee and hip replacements etc! How is it possible to be safe????

  4. Janet says:

    These reflections remind me of old-fashioned common sense.

  5. MW says:

    Thank you for speaking in realistic terms and without ‘rose colored glasses’.

  6. DM says:

    Dr. Curtin – do you really think your colleagues on the various quality panels are “tradition-bound, arrogant, and self-important “leaders…who publish inept, misguided, naive, insensitive, power-driven regulations?” Isn’t this just a little arrogant on your part?

  7. Anonymous says:

    I LOVED what you had to say about quality. And you are right — it used to be part of our DNA…Go for it!

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