How Much Evidence is Enough?

October 28, 2009

If it doesn’t directly impact clinical care, is it still worth doing? That’s the question I was recently asked while speaking to a physician group.

(Before I go any further, let me say that I welcome having my beliefs questioned. It’s one of the benefits of being able to travel all around the country and interact with so many wonderful people. I have many opportunities to learn and to become better.)

Anyway, a physician in the room stated that he did not believe the patient satisfaction survey was of much value due to the fact that it does not impact clinical outcomes. He also felt that a patient could be very satisfied, yet not receive good clinical care.

Let me address the second comment first. I agree. It is possible for patients to rate their care high in a survey and still not receive great clinical care. This is where an organization’s values come in. I don’t know of any organization that feels good if patient satisfaction is high and quality is not.

The inverse is also true. Many times an organization’s clinical quality can be excellent but other issues can lead patients to feel they did not receive excellent clinical care.

My comment the other day to a group of physicians in an academic medical center was, "Let’s have the patient’s perception of care match the clinical quality you are providing."

Now, let’s go back to the challenge that started this blog entry: My first attempt to link the survey to the issue of clinical care was to read the questions. How well was your pain managed? How well were your needs responded to? How well were your questions answered? How well were things explained to you? How well were your home care instructions explained? I explained that I feel each of these can impact clinical care.

The physician disagreed, stating that these issues still may not change the clinical outcome. I then said, "So if a patient’s clinical outcome will not be impacted, then you don’t want your patient’s pain managed? Nor call lights answered?" The physician answered that of course he would want these steps to be taken.

That’s when it hit me. While I can connect the dots and also show more research that indicates a connection between patient satisfaction and clinical outcomes, the evidence really isn’t the point. There are times when even if actions do not impact the clinical outcome, certain behaviors and actions still need to be done.

Hospice caregivers do great work. Do their efforts change the clinical outcome? My first grandchild was stillborn. While the care and support given to my son and daughter-in-law did not change the clinical outcome, were they worthwhile? Yes, without a doubt.

Why do some people fight making some basic changes? I can’t take inventory for others, but based on years of experience, I do have some observations of my own.

For some people, it has to do with not being comfortable. If I am asked to do something that I am not comfortable doing and can come up with a reason not to do it, I have found a way to stay in my comfort zone. For others, I believe it is the fear of failure. They would rather not try at all than try and fail. I believe this is one reason best practices are hard to transfer in healthcare.

Some people may feel they are the voice for others. Have you ever noticed when someone is pushing back, he or she may often say, "Everyone," "Most people," or "Others," rather than coming out and saying, "Here is how I feel." Still others may feel they need more data before they can make a change.

It’s that last group of people, the data-seekers, who bring me back to the point. How much evidence is enough to make a change worthwhile?

I have come to this conclusion: There are times in life when we do the behavior even though there is not overwhelming research data to support it. We do it because it is the right thing to do. I can think of no reason more powerful than that one.


Quint Studer

Quint Studer


9 Responses to “How Much Evidence is Enough?”

  1. Bill M. Says:

    I concur with your comments. It goes along with the idea of having faith: You believe and do certain things even if you’re not sure why, but deep down we know it’s right. Research may eventually prove why certain service behaviors are beneficial to the patient’s recovery. However, caring for patients and their families often requires that we look more into our hearts than our heads.

  2. Ella Beth Goetschius Says:

    When I meet people who are resistent to change, I remember the saying

    “Without change, there would be no

  3. Aleta Rauch, RN, MSN Says:

    After reading your blog regarding “How much evidence is enough”, I remembered many times I have called a MD with, “something was wrong” and I didnt have big evidence of problems but I knew it was right to call and my intuition as a nurse was ignited……sometimes, this would prove right and we would prevent a code, other times, it seemed my call was just a false alarm, but it hasnt stopped me from calling in 17 years! Following the gut about the right thing is the right thing.

  4. Several times a week we see patients that have been receiving care that at best was suboptimal and often far worse with resulting damage to hearts, brains, kidneys, eyes and feet. Damage or loss is irreversable. Yet they perceive having received good or excellent care when if fell far short of national guidelines. To truly understand how much they have been harmed by lack of adequate care brings a stark realization, self doubt and occasionally open hostility. That may be directed toward to us in informing them, or toward prior providers. The challange here is not when there is not enough evidence to conclusively prove, but when there is such evidence yet providers consistantly fail to act on it, successfully placating with platitudes instead.

  5. There was a story in yesterday’s Wall Street Journal( engaging families in the management of premmie care. Instead of family members being “a problem” they now become a partner.
    As we move to patient (and family) centered care models, we may find that the evidence for such factors as compliance and adherence, comprehensive medical information, sharing of medical records and perhaps even medical liability change as patients become more “satisfied” with the overall level of their medical care. While grounding our health care in evidence is essential, it is not comprehensive

  6. Wendy Says:

    I am feeling pretty disheartened by the new survey CMS is putting in place for home health. Our current patient satisfaction program has had dramatic results, and as one of the developers, I have felt very committed to the philosophy behind it. Now we have to change to a new survey tool, and a new way of selecting people to survey. Instead of 100% of discharged patients, it will be a number of all active patients. The cost of running dual survey makes that impossible. Our reward and recognition program relies on patient comments, but we may not have access to that data from our vendor due to CMS requirements for patient confidentiality. The economy has forced our parent system to pare down and focus, and patient and team member satisfaction are not on the list of priorities. I’m sure we are not the only organization in this situation. That along with healthcare reform, whatever that may turn out to be, makes me wonder what sort of service patients will be receiving in 2010, from all healthcare organizations. Do you have any words of encouragement?

  7. Mark Welch Says:

    The very last paragraph said it all, especially the statement, “We do it because it’s the right thing to do.” This comes down to personal character, ethics, and priorities in life, and for me personally, religious faith. Any rationale for resisting good change or the right thing to do is just noise.

    This certainly makes a case for how we raise our kids. Doing the right thing certainly necessarily instinctual.

  8. Mark Welch Says:

    I really need to fix that last sentence. It should read, “Doing the right thing isn’t necessarily instinctual.”

    Sorry for the poor proof-reading.

  9. jim Says:

    I had the same kind of revelation yesterday evening while watching the Yankees in the world series. My wife is the ultimate fan and made this observation. The manager Joe Girardi was witnessing one of his relief pitchers doing a great job to get out of an inning (maybe even considered a super performance) however when it came to the third out he switched pitchers. Joe had all the information that supported the probabilities of a successful decision however he was ignoring the reality of what was happening to stay with the current pitcher. I wonder if the evidence becomes to much of a crutch when making a decision?..

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