Outpatient Health Care Quality: Think Globally, Act Locally

In thinking about the dilemmas that must be faced to promote outpatient health care quality, I have been reminded of 2 informative books on work, motivation, and incentives. The first, Douglas McGregor’s The Human Side of Enterprise delineated “Theory X” and “Theory Y” as 2 conflicting interpretations of people’s motivation to work. At the risk of oversimplification, Theory X assumes that people naturally dislike and avoid work and that managers must control and even threaten workers to compel them to do their jobs, whereas Theory Y assumes that people naturally enjoy expending effort and using their imagination and creativity and can be relied on to direct themselves. The parallel with efforts to improve health care quality is the current conflict between advocates of professional self-regulation and advocates of external regulation, including mandatory error reporting to external organizations. The second book, William Ouchi’s Theory Z: How American Business Can Meet the Japanese Challenge, posed a third alternative, Theory Z, a management philosophy blending Japanese and American approaches. It is not only Ouchi’s hybrid management theory but also his description of Japanese quality control circles (Q-C circles) that is instructive. The essence of Q-C circles is their small scale and autonomy, power sharing by management, maximum participation by all workers in a specific work location, and use of statistical analytic techniques in studies. The bottom-up devotion to quality in processes and outcomes exemplified by more than 100 000 Q-C circles has been crucial to the post-World War II revolution and continuing progress in productivity and quality in Japanese industry. Despite the American health care system’s historical reluctance to embrace management techniques found to be successful in other areas of the American economy, some recent advances in measuring and improving outpatient quality are worthy of attention. First, as a key part of its initiative to enhance its approach to physician certification, the American Board of Internal Medicine has developed practice improvement modules for self-assessment, enabling internists to track samples of their patients with selected conditions, to evaluate their patients’ status, to develop and implement their own customized quality improvement initiatives,and to evaluate their performance as clinicians. Second, with support from the Agency for Health Care Research and Quality, the American Academy of Family Physicians (AAFP) established the AAFP Center for Evaluation and Research in Patient Safety in Primary Care in 2001, and in 2002 developed a Web-based medical error-reporting system meeting federal confidentiality standards. Based on these AAFP efforts, numerous researchers, including 42 family physicians in the AAFP’s National Network for Family Practice and Primary Care Research, have been developing a taxonomy of errors and are conducting research on the incidence, distribution, and etiology of errors. A particularly relevant study, published in 2004 by Dr Nancy Elder and her colleagues, tested the idea that physicians who report errors proceed to make practice changes simply as a result of participating in error reporting. In this study of laboratory and imaging test processing in 8 family practice offices, Elder and her coauthors held 18 focus groups with 139 participants and found that “while participants wanted major changes like electronic health records, more staff, and improved space to