When it comes to eliminating medical errors and outcomes variation, some chief medical officers say, too much emphasis has been placed on castigating individual physicians and not enough on using the best available evidence to improve a whole system.
Those CMOs are leading their organizations away from the "I gotcha" model of quality assurance toward a broader, process-driven method that values and rewards the same thing physicians do--patient care. Discussions with four CMOs reveal that despite serving widely different markets through diverse types of healthcare organizations, medical staff leaders face similar challenges in balancing time, money and energy while garnering support for new quality programs. They agree that one of the tougher parts of their job can be convincing physicians that while performance improvement may have some traits in common with utilization review, its ultimate goal is to enhance quality, not cut costs (although it often does that, too).
These leaders use an arsenal of tools to bring even independent-minded physicians into the era of accountability. They include a more consistent use of clinical pathways or guidelines that include the latest medical literature, creating a supportive culture, and utilizing information systems that provide optimum access to both in-house and external data.
"What's more important is beginning to establish what is the best practice and then sharing that information with physicians and getting physician input and leadership as to how the process can be improved," says Lee Hammerling, M.D., CMO at the 12-hospital ProMedica Health System based in Toledo, Ohio.
"Continuous performance improvement should provide the resources and support to drive physicians to best practice."
ProMedica has more than 2,200 physicians on its medical staffs. Another 170 work for the system through an employment model, and 350 physicians have affiliation agreements or exclusive contracts with ProMedica.
Admittedly, the "fear factor" can rear its head when a physician's own practice is being evaluated, Hammerling says. But because "physicians love the scientific method," he and others argue that when doctors are provided an opportunity to understand their own data and its relevance to national benchmarks, these innately competitive professionals actually relish the chance to improve.
"When you're trying to modulate a behavior with exceptionally sophisticated people, you have to show them data that demonstrates outcomes and patient satisfaction make sense, not only in costs but in patient care," says Jeffrey Zaks, M.D., CMO and vice president of medical affairs at Providence Hospital and Medical Center in Southfield, Mich. The 600-bed tertiary hospital has 1,000 doctors on staff. Zaks also is executive director of the Society of Chief Medical Officers, a group of hospital CMOs who compare experiences, benchmark activities, share problems and review solutions.
Hospitals help guide physicians in a number of ways, Zaks says, including adopting care management plans. For example, all patients with asthma get coaching on environmental changes they need to make in the home, and the same series of initial steps is taken with patients that have pneumonia. At Providence, the quality management team employs a hybrid system, with a focus on high-volume, high-cost, problematic diagnoses. Information from national databases is gathered, then reviewed by the physicians, who often wind up creating a custom database that uses both internal and external benchmarks, Zaks says.
"It's really more of a road map and not what some detractors have referred to as cookbook medicine," Zaks insists. "If you have a pathway, a prompting system for certain diseases, you improve outcomes and decrease costs."
One of the properties of performance improvement is careful examination of each of the elements of decisionmaking, Zaks says, using medication administration to illustrate his point.
"There may be 10 different pieces, from writing the initial order to transcribing to filling and dispensing. In performance improvement, we believe in measuring outcomes, so if you're looking at medication administration errors, you develop a tool that looks at all the medications distributed in a particular unit. What changes can be made independent of the people involved in the process?"
In a more traditional quality assurance model, "we see a medication error, call the nurse or doctor in, yell at them, write up a report, take a disciplinary action and out the door they go," Zaks says. "It never really changes anything."
He says when a failure of action is recognized, the first thing to do is to go through every action and find where the problem lies. "The problem is almost never a person," Zaks says.
Charles Mullican, M.D., is CMO of Heartland Health, a not-for-profit, community-based regional medical center in St. Joseph, Mo., with a mix of 210 employed, contracted and independent physicians. Like Zaks, Mullican says a critical step in promoting physician performance improvement is to create a culture that supports a clinical care management infrastructure.
"You need people to help doctors, people who will research those evidence-based standards of care, create protocols, choose quality measures, put systems in place to analyze variance and manage what JCAHO calls 'sentinel events,'" Mullican says. "And you have to have a way of aggregating the results of all this stuff, a group of folks looking at the measures and strategically planning for performance improvement in the future. It's a cycle."
That administrative structure must be in place to promote physician engagement, he says, because few doctors have the time to organize themselves. In addition to a medical staff president who oversees the medical executive committee and the processes of peer review and credentialing, Heartland's structure is built on the foundation of its nine-member quality management board.
This body is a new combination of the old medical staff quality committee and the hospital quality committee. It is chaired by a physician executive and organized around a series of service lines. Each is led by an administrator paired with a doctor from the medical staff who meet once a month with an agenda to design and approve order sets, establish measurements, evaluate variance and monitor the progress of their performance improvement projects. Beginning in January, when Mullican began appointing the physician members of the new quality board, the doctors have been paid an annual salary, capped at $50,000 per physician, for their "contracted" quality improvement services. The cost will come from each of the service lines represented and will total $500,000 per year.
But CMOs should beware resistance that can result from any confusion or contradiction in the infrastructure, warns Frank Claudy, M.D., vice president of medical staff affairs at the 502-bed Genesis Medical Center, a not-for-profit community hospital in Davenport, Iowa. Claudy leads a medical staff of 403 doctors, 27 independent associated professionals and 70 allied health providers.
"When coming up with all these committees, you need to be careful to coordinate them with the understanding that the medical executive committee is the primary group overseeing quality," Claudy says. "Many hospitals put in a process that inadvertently diminishes the job of this body. That cannot happen. That's your elected group, and that's one of the places where the leaders come from. All roads should go back to the medical executive committee."
Having been a medical director for a primary care group, he says many of the strategies for performance improvement that work in hospitals translate to group practice, without the same degree of regulation.
If the systems are designed with patient care in mind and truly perceived by physicians as improving care, Mullican says, doctors really do take to them.
"Efforts to engage physicians around anything else are fraught with trouble or met with resistance," he says. "If they're seen as cost-saving or revenue-enhancing, they're not greeted with much enthusiasm."
Obstacles: the data game
Finding and using trustworthy data that works with an organization's existing information systems can be a challenge, though not insurmountable. While it can be tricky for hospitals to present consistent data that is relevant to every practice, Claudy says a helpful place to start has been the JCAHO-required database that allows users to compare state and national data so individual doctors can compare their practice with established norms.
He notes that Genesis has a second, risk-adjusted database that helps with more precise practice comparisons and recommends that every CMO be aware of and use some type of similarly adjusted program. In addition, Claudy says proprietary databases are available. For example, companies such as Solucient and GE Medical Solutions use MedPAR data that can be helpful in displaying information in new ways.
Some organizations, including his own, build custom databases from the ground up. "We're doing this for cardiovascular patients right now, apart from the hospital's system," Claudy says. "It's a totally searchable database where we can compare different interventions and finely hone what we offer. We get results that are a lot more accurate than anything we can extract from the hospital's master database."
These initiatives can take several years to reach tangible benefits, CMOs agree. Some doctors may get restless with the slow pace of task assignment, infrastructure development or computer systems. Part of the CMO's job is to encourage diligence and patience.
"All of the information systems we've had for the last 25 or 30 years have been cost-based or claims-based," Mullican says. "That doesn't help a doctor much. This whole effort is so information-dependent that you're almost a prisoner of the system you have in place."
If it is based on cost accounting of charges accumulated by various procedures around the hospital, it can be difficult to translate into a meaningful clinical goal for physicians, he says. For example, the system at Heartland doesn't yet have a good way of calculating the number of eligible patients dismissed with congestive heart failure who are receiving an ACE inhibitor. Manual chart review is necessary to see if Heartland is meeting HCFA indicators for this treatment, Mullican says.
"Say 85% are eligible, what percent are actually getting them?" he asks. "We may need clinical management software that sits on top of the cost management system."
Often physicians have no idea what their own data is, he says, and different guidelines are meaningless tools until doctors understand their own practices.
But a revelation often occurs after physicians are presented with convincing, risk-adjusted evidence that they may in fact be treating patients differently.
"The transformation is dramatic," Hammerling says. "They say, 'Okay, what do I need to do and how?'"
When you don't have a problem screaming at you, how do you encourage improvement anyway? Claudy says a variety of incentives are justifiable as long as the goals remain clear.
Trying to qualify for an award is a legitimate way to go after a goal, Claudy says. "Whether it be for the lowest error rates in administering medication or the best outcomes from treating heart failure or the highest patient satisfaction, some staff get excited about that," he says.
Or maybe an organization seeks recognition for excellence through collaboration. Claudy says Genesis came up with a chest pain protocol for patients who might have heart disease and shared it with other hospitals in town because it helps communicate a consistent message to the community.
Medical staff also can be encouraged when a hospital or group demonstrates that its resources are better used as a result of performance improvement initiatives. If your doctors are actively participating in the strategic planning and capital budget/acquisition cycles, Claudy says, you can show them how process improvements allow them time to do other things they might be interested in.
The real challenge for CMOs is to change the basis of healthcare competition from cost to quality, Hammerling says. To this end, one of his goals is to differentiate the ProMedica system in a way that is identifiable to payers and patients. He believes that while physicians also want to be associated with strong healthcare systems that stand for high quality, it is important to construct models of compensation that reward quality performance.
ProMedica's Quality Incentive Program offers annual bonuses based on an individual's performance. The bonuses average between 15% and 20% of the physician's annual salary.
"It needs to be significant to convey the message that the work they do is important," Hammerling says. "We're using business and financial incentives as a carrot rather than a stick. We want quality, and to see that physicians make the extra effort, the system is stepping up to pay for it. We'll reward it."