Since we keep failing to meet them- shall we get rid of targets?
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Since we keep failing to meet them- shall we get rid of targets?
Discuss any aspect of type I or type II diabetes mellitus here
At a King's Fund meeting about Leadership this week someone asked if we should get rid of targets and focus on teaching health professionals the right behaviours so they did the right things. An A and
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Forums » Open clinical » Diabetes » Since we keep failing to meet them- shall we get rid of targets?
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Since we keep failing to meet them- shall we get rid of targets?
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Since we keep failing to meet them- shall we get rid of targets?
posted at 24/5/2012 10:14 PM BST
on bmj.com
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Posts: 93
First: 18/3/2011 Last: 4/3/2013 |
At a King's Fund meeting about Leadership this week someone asked if we should get rid of targets and focus on teaching health professionals the right behaviours so they did the right things. An A and E doctor said that an audit of pain relief in children in A and E found that only 38% of children who needed it got pain relief in the first 20 minutes of walking through the door. The same Audit 6 years previously found the figure was 40%- so things had got worse since the target was measured. Last week too the audit commisison said people with Diabetes were still not having the nine things checked that they should have checked- their feet, cholesterol, blood pressure, eyes etc. Are targets a waste of time - they must be if no one tries to meet them- so rather than reducing people to targets- would we not be better encouraging health care professionals to do what they know is right? |
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 24/5/2012 10:53 PM BST
on bmj.com
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Posts: 3045
First: 27/3/2012 Last: 20/5/2013 |
I do not think that setting targets could deviate us from achieving our goals. The main purpose of setting appropriate targets is to reach our preset goal with ease & in a systematic way. Further it helps us to set uniform patterns of systematic treatment. |
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 25/5/2012 1:56 AM BST
on bmj.com
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Posts: 324
First: 23/12/2011 Last: 3/5/2013 |
I am way too early to really have any say in this but I think that targets whether they are met or not are good as it gives a driver to do something. I know there is a lot of anxiety these days about tick box medicine but at the same time I think having them is better than not. In my unprofessional and inexperienced opinion |
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 25/5/2012 12:34 PM BST
on bmj.com
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Posts: 453
First: 29/4/2011 Last: 14/5/2013 |
"Would you tell me, please, which way I ought to go from here?" "That depends a good deal on where you want to get to," said the Cat. "I don’t much care where--" said Alice. "Then it doesn’t matter which way you go," said the Cat. "--so long as I get SOMEWHERE," Alice added as an explanation. "Oh, you’re sure to do that," said the Cat, "if you only walk long enough." (Alice's Adventures in Wonderland, Chapter 6) COMMENT: Need I say more? |
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 25/5/2012 12:36 PM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
Hello DrMK: Thanks for your quite smart question. Although It does not make-me necessarily a better doctor, I am indeed a mature physician. I am very careful about the so-called "treatment targets" in medicine. They tend to make us silly doctors. My opinion goes in line with the text below (adapted from the Ten Commandments of Therapeutics by Prof. John S. Yudkin): You Shall not worship Treatment Targets, for these are but the creations of Committees" “Sometimes consensus groups come up with‘treatment targets’ that tell physicians what patients’ lab numbers should look like. But physicians need to take individual patients’ bodies, lives, and needs into account. An example: a consensus committee might issue a treatment target for glucose (blood sugar) control. They might say everyone should have normal blood sugar. But imagine a patient who is an 80-year-old woman who has been falling a lot. Lowering that woman’s blood sugar could increase her risk of a big bone fracture from a fall. So she should NOT be treated glibly according to a Treatment Target that might be perfectly reasonable for an otherwise healthy 30-year-old woman. Physicians and patients should especially beware any consensus issued by a committee of people who have had financial ties to drug and device makers.” By the way the target of achieving normal glucose levels had been unnecessarily killing diabetics in the wards, in the ambulatory setting, and in the ICUs with associated Hypoglycaemias. All Best, Joey |
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 25/5/2012 3:55 PM BST
on bmj.com
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Posts: 134
First: 25/5/2011 Last: 17/5/2013 |
We should not misinterpet the phrase "Nobody tries to meet them" to mean that professional health care staff deliberately try to provide a less than excellent service. What people may not recognise is the difference between clinical staff - those who have chosen to devote their lives to others, and professional managers - those who have chosen to devote their lives to themselves and their personal advancement. Clinical staff have been trained to complete a task - i.e. not walk off halfway through dealing with a patient, whereas managers are quite happy to leave a project at any point to take on "a new, exciting and challenging role within the organsiation". Now guess who sets targets? The result of this difference in philsophy is that loyal, altruistic staff who fear failing their patients are set achievement targets by people who cannot empathise or understand how hard any failure will affect the morale of the staff. For one group, having said that you'll aim for the stars but only actually getting up the stairs is merely an outcome measure. For the other group it is a dire failure of their professionalism and makes them think that they have failed a whole group of patients. The guilt is overwhelming, as is the fear of shame when they are judged by their professional peers as being sub-standard. Being responsible and resourceful people however, they immediately investigate what went wrong. They soon discover that the specialised equipment, space ship and launch pad which they would have needed for the trip to the stars not only wasn't ordered, but hasn't even been invented. Dismayed by this, they question the reptilian life form now managing them. They ask "Why didn't you just ask us to get up the stairs? You knew that it was impossible to reach the stars without a space ship, and yet this is what you asked us to do" The reply comes, "Well if I had done that, you would have only tried to get half-way up the stairs". After a few of these experiences and seeing managers regularly depart to "a new, exciting and challenging role within the organsiation", you will soon find that the clinical staff who are left to keep working at the coal face draw closer together as a misunderstood minority, and establish their own way of working so that the job gets done. Whenever they need somethng to improve the service they are told that they need to "formulate a business plan". Something that they have never, of course, been trained to do. Yet this, they are told, is the "way things are done in a modern business environment". It might be simpler just to tell them "You are stupid, out of date and know nothing. Now go back to work". A manager is then employed to draw up targets and explain why anything that the staff want is wrong, unrealistic and frankly demonstrates just how inadequate as human beings they really are. Much new language is used involving pots, ring-fences and the adjective fiscal. Soon after this the manager will leave and move on to "a new, exciting and challenging role within the organsiation", and the new one will then have to attend many meetings to monitor the targets that the previous one set. Older, world-weary members of the clinical team are then usually asked not to attend staff briefings in future if they are just going to be negative and undermine the smooth running of an organisation and thereby "hold back progress in the department". In the end they just shut up and keep coming to work. If anybody thinks that clinical staff are failing at anything, then it is your duty to report them. If some other life form and philosophy is setting stupid, unrealistic targets, just who should the clinicians tell? In my experience the higher the target setters are placed, the less access is available to them to point out the errors in their thinking, and also the less likely they are to listen. In the present form, let's get rid of targets. |
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 25/5/2012 7:36 PM BST
on bmj.com
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Posts: 33
First: 11/2/2011 Last: 2/5/2013 |
ONe shouldn't cofuse measuring performance with targets. In the past medical leaders have advocated them when it meant they could use them as a means to get more resources. Though we should all be measuring our own efficiency and performance, the problem with the target culture is that all the energies become devoted to meeting that target often by means that one could consider fraudulent; particularly as the disincentive from fudging the figures is small compared with the kudos of meeting the 'target'. The effort devoted to meeting the 'target' would be better spent making sure one is constantly improving by assimilating and disseminatinng best practice and developing staff.
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 26/5/2012 11:08 AM BST
on bmj.com
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Posts: 27
First: 25/9/2011 Last: 13/2/2013 |
In Response to Re: Since we keep failing to meet them- shall we get rid of targets?: Dear Joey, Thanks for the post and bringing back great memories. I worked with John Yudkin at the Whittington Hospital in Highgate for a short time as a medical student and I can picture sitting in his study group right now completely absorbed in his eminent wisdom. Hello DrMK: Thanks for your quite smart question. Although It does not make-me necessarily a better doctor, I am indeed a mature physician. I am very careful about the so-called "treatment targets" in medicine. They tend to make us silly doctors. My opinion goes in line with the text below (adapted from the Ten Commandments of Therapeutics by Prof. John S. Yudkin): You Shall not worship Treatment Targets, for these are but the creations of Committees. “Sometimes consensus groups come up with ‘treatment targets’ that tell physicians what patients’ lab numbers should look like. But physicians need to take individual patients’ bodies, lives, and needs into account. An example: a consensus committee might issue a treatment target for glucose (blood sugar) control. They might say everyone should have normal blood sugar. But imagine a patient who is an 80-year-old woman who has been falling a lot. Lowering that woman’s blood sugar could increase her risk of a big bone fracture from a fall. So she should NOT be treated glibly according to a Treatment Target that might be perfectly reasonable for an otherwise healthy 30-year-old woman. Physicians and patients should especially beware any consensus issued by a committee of people who have had financial ties to drug and device makers .” By the way the target of achieving normal glucose levels had been unnecessarily killing diabetics in the wards, in the ambulatory setting, and in the ICUs because of increased Hypoglycaemias. All Best, Joey Posted by Joey Rio |
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 26/5/2012 5:06 PM BST
on bmj.com
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Posts: 453
First: 29/4/2011 Last: 14/5/2013 |
It seems to me that the conversation is focused on abuse of targets rather than their appropriate role in providing a practioner with goals (much preferred term than targets because they express an ideal that may or may not be achievable or even applicable in an individual patient). I was at the forefront of the develpment of evidence-based guidelines in diabetes and it's associated cardiovascular risk factors beginning with being the Chair of the DCCT Data, Safety Monitoring Committee followed by being the founding Chair of the National Diabetes Education Program. (NDEP). All our efforts are and have been to provide the practicing community with the scientific basis for caring for people with diabetes. Unfortunately, as so eloquently posted in this series, guidelines can and have been abused. They are and were intended to be maps, not targets. They were not intended to be used to determine compensation of practitioners or to blindly determine the quality of an individual's or a practice's quality of care. I again point out as have Joey and others and as embodied in the EASD/ADA consensus statement: guidelines are just what the name implies, guidelines, to be used to guide the patient and his or her practitioner in setting individual goals taking into account a host of epidemiological,, socioeconomic and personal variables. Appropriate use of guidelines will help in the process of setting an individual's goals in our attempts to prevent or delay complications and their associated morbidity and mortality. The inappropriate use will harm patients, practitioners and the health care system as a whole. |
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Re: Since we keep failing to meet them- shall we get rid of targets?
posted at 26/5/2012 10:36 PM BST
on bmj.com
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Posts: 27
First: 25/9/2011 Last: 13/2/2013 |
How have we possibly allowed this bizarre situation develop where men and women of great wisdom and knowledge continue to strive to improve patient care while those who are either "cognitvely challenged" or at best ignornant of true human epidemiology are given the task of supervising us. Is it too late to redress the imbalance here? |
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