#MEQAPI – Tweetchat Sep-27 2018 3:00ET Compliance Shaming

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.

There is an unfortunate holdover from the old days of medical paternalism that continues to bear a rancid fruit of mistrust and anger among patients and physicians – the label of “non-compliance”.

Here is how Stephen Brunton, editor in chief at the journal of clinical; diabetes puts it:

Medicine has a history of paternalistic and top-down approaches to patient care; patients had to follow our instructions, and if they did not, we labeled them “noncompliant.” (How dare they ignore our erudite advice?) More recently, as we have become more enlightened in our recognition that input from our patients needs to at least be considered, we began using a term many of us thought of as more politically correct: “adherence.” However, this term also suggests a power differential, and although we may believe it to be less offensive, it, too, misses the mark. We have simply slapped a new label (“nonadherent”) over the old “noncompliant” label, but we are still blaming and shaming our patients.


The term “non-compliant patient” conjures up images of an intransigent know-it-all patient who “thinks they know better than the doctor”, and who digs in their heel for no other reason than to be bull-headed and contrary. However,  more typical reasons that patients do not follow doctors’ orders are social determinants of health such as lack of money, lack of accessibility, and impracticality in the context of the lived environment. Physicians often do not know how much prescribed medications cost, nor what practical difficulties the patient may experience in their lived environment.

When a patient must choose between the brand-name medication and buying food, or when getting the prescription filled will require two buses and a stiff walk, they may simply not be able to stay in compliance with doctor’s orders. Likewise, an instruction to use an ice pack and have bed rest may be good advice, but impractical when missing a day’s work means risking the rent or losing a job, and the nearest ice machine is a bus trip away.

Part of escaping the blame and frustration cycle is to make sure that care plans are developed with patient participation, and will therefore be more closely aligned to the patient’s goals, priorities, and capabilities. Quality, let’s not forget, is a function of how well the outcomes meet patient’s goals.

We will discuss the various dimensions of compliance shaming

Compliance Shaming


  1. Policy: What laws, policies, rules, regulations, etc. enhance or degrade patient ability or willingness to adhere to  a care plan?
  2. Equipment: How do equipment and devices enhance or degrade patient ability or willingness to adhere to  a care plan? Everything from transport to gowns with no back.
  3. Measurement: How do quality, safety, and performance metrics enhance or degrade patient ability or willingness to adhere to  a care plan?
  4. Environment: What environmental factors enhance or degrade patient ability or willingness to adhere to  a care plan? Everything from the room where care is provided, facility location, privacy, etc.
  5. People: How do the people in healthcare – the staff, cleaners, technicians, clinicians, researchers, public, media, friends, family, etc enhance or degrade patient ability or willingness to adhere to  a care plan?
  6. Materials: What effect does the “medical stuff” patients need enhance or degrade patient ability or willingness to adhere to  a care plan? – the medications, instruction sheets, information, medications, test results, etc


MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered. We expand this to include Accessibility, STEEEPA.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.


The Author and Moderator: Matthew is a principal analyst for healthcare improvement at the Washington D.C. based firm of Whitney, Bradley, and Brown (WBB), and is a strategic adviser and board member at the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and blogs regularly for Physician’s Weekly.




Published by

Matthew Loxton

Healthcare Analyst using Lean Six Sigma, Knowledge Management, & Organizational Learning to improve healthcare http://linkedin.com/in/mloxton

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