The push is growing for physician involvement in quality: Act now

Problem is a 'profound challenge'

(Editor's Note: This is a two-part series on physician involvement in quality initiatives. This month, we cover effective ways to involve physicians. Next month, we will give strategies to address resistance from physicians to evidence-based care.)

The new medical staff and upcoming leadership standards from The Joint Commission and the recent Centers for Medicare & Medicaid Services (CMS) ruling stopping reimbursement for certain preventable conditions have something in common: All are strong incentives to involve physicians in quality initiatives.

There is no question, though, that hospitals are struggling with this. Only one-third of respondents to a survey conducted by the Tampa, FL-based American College of Physician Executives reported that physicians were "very supportive" of patient safety projects. (You can access the complete survey results and related articles at www.acpe.org/quality.)

"This is a profound challenge for most health care institutions," says Alice Gosfield, a Philadelphia-based attorney and consultant specializing in quality improvement.

Physicians are so beleaguered by the multiple demands on them, that to engage them in quality improvement requires engaging with them on their business case for quality, says Gosfield.

"Physicians care about quality profoundly, but not always in the terms in which hospitals seek their involvement," she says.

Seek to understand physicians' perspectives, and engage them in ways that will respond to their needs, advises Gosfield. "Then, they can be real partners and collaborators around quality and not mere 'customers.'"

There often is a disconnect between physicians and hospital administrators, adds Donald L. Mellman, MD, MPH, MBA, FACHE, a Tampa, FL-based consultant specializing in health care quality. "Non-physician leaders speak a different language than physicians. The chief medical officer should be a translator for both sides and try to get them to work together," he says. "The most important thing, in my experience, is alignment of incentives."

It's not unusual for hospital administrators to subvert the peer review process for physicians who are high-volume admitters, to make it more favorable for those physicians because they bring in a lot of money to the hospital, notes Mellman.

When quality professionals see things such as this occurring, or see that there is poor quality and nothing is done about it, it's "a horrible thing because they really care, and these are the people who are often not listened to," says Mellman.

To prevent this disconnect, the medical executive committee should be responsible for quality, but this is not happening in most community hospitals, says Mellman. "Ideally, the director of quality improvement should report to the chief medical officer, with a zero tolerance for disruptive behavior, which adversely impacts quality," he says.

Quality professionals should be 100% supported by the person they report to, who must be 100% supported by the CEO of the hospital, who must be 100% supported by the board, says Mellman. "And everybody should have a zero tolerance for poor quality and poor patient safety," he says.

Physician champion is key

"In our experience, it's essential to have a physician champion," says Thomas Rosenthal, MD, chief medical officer at University of California at Los Angeles Medical Center. "When you've got a physician champion, you've got a fighting chance to make it happen. That holds true for both academic centers and community hospitals."

Since you are asking physicians to change the way they do things, having peer leadership is essential, says Rosenthal. When physicians are given data that don't agree with their own experience, or that make them look bad, the first thing they tend to do is challenge the data.

"And that is one of the roles of the champion — to step in and say, 'I don't look so good either, but I am not challenging this, and I believe it's correct for these reasons,'" says Rosenthal.

In turn, the quality professional should give data and literature to the champion so that together they can craft a change plan, advises Rosenthal. Dramatic improvements can be made if physicians actually buy in to the reason for the change, he adds. For example, UCLA was able to dramatically reduce central-line infections in its intensive care units (ICUs) because physicians bought in to the practice changes.

"One of our infectious disease doctors has taken the lead and works with the physician and nursing directors in each of the ICUs," says Rosenthal. The infection control department provides monthly review data, so that physicians can track their infection rates and compliance with benchmarks.

Rosenthal attributes the success to a general agreement among physicians that there was a problem, and that it could be improved by making specific changes. "And further, that it was not going to destroy their practice or be disruptive to them," he says. "You need to have some cognizance that if you are going to ask the practicing physicians to change, it can't be terribly disruptive to them."

Your physician champion may not always be who you expect. "The champion may not be the person who is the titular head," says Rosenthal. "It may be the thought leader or the youngest person, or someone who is willing to own it from a moral point of view and truly believes the data."

When a goal of improving compliance with giving antibiotics within one hour of surgery was set, the matter became a practical one — who was actually available in the OR to give the medications. The anesthesiologists were there doing their preoperative workup during that time, so they were approached. "We got our anesthesiologists to agree to be an aggressive part of this thing and they made it happen," says Rosenthal.

Previously, when anesthesiologists were asked to perform an assessment required right before surgery, they refused, saying it was the surgeon's job. "I thought for sure they would say the same thing about the antibiotics, but they didn't," says Rosenthal. "They stepped up and said we believe that this is a good thing for us to be doing, and were willing to be engaged in the actual dispensing of the medicine." As a result, the hospital is now in the top fifth percentile for that measurement.

At Columbus (OH) Regional Hospital, physician champions co-lead interdisciplinary teams and work alongside clinical nurse specialists, says Katherine J. Wallace, RHIA, CPHQ, director of medical quality management. "The organization is committed to using their time wisely. Their involvement is kept to an as-needed basis," she says.

The clinical nurse specialists provide the most current research, and work with the physician champion to design processes to implement that evidence. "The most effective way to engage physicians is to respect their time and to implement identified plans so that they see the benefit that their involvement brings," says Wallace. In the hospital's most recent physician opinion survey, "efforts to continuously improve quality" was better than the 90th percentile, she reports.

Quality professionals also are members of the interdisciplinary team, providing data and tools to facilitate meetings. "Physician champions can certainly help defend data, if necessary," says Wallace. "Their role is also to defend the evidence-based practice to other physicians. We have found that physicians are naturally curious about their performance compared to others."

Physicians are provided with blinded data by physician so they can see their performance compared to other physicians' performances. "This generates a lot of questions, and even requests for medical record numbers so that the physician can follow up on their own cases," she says.

At Homestead (FL) Hospital, quality professionals approach individual physicians to ask if they would be willing to be the physician champion for a particular area, says Jill White, director of performance improvement. "They work closely with our performance improvement staff, as well as hospital staff and other physicians, on identifying opportunities and piloting strategies for improvement."

If you're looking for a champion, identify a physician you believe would be a good fit and then move forward, advises White. At Homestead, hospital staff do most of the legwork in actual data collection, but the physician champion reviews the data and becomes the spokesperson in communicating to the medical and hospital staff about these projects. "In this way, they feel ownership of the problem and solutions," says White.

Quality dashboards are presented at all medical staff meetings, says White. "Physicians want to do a good job. Sometimes just sharing information and opportunities creates momentum and results improve," she says.

Become a clinical insider

It's often easier for "insiders" to obtain buy-in from physicians, notes Rosenthal — for example, a nurse in UCLA's surgery department is part of the quality management team. "She has credibility with the chair of the department so when she speaks and says, 'Guys, we need to do this,' they listen."

If you don't have a clinical background, align yourself with physician and nurse leaders at your organization, he advises. "Take up a modest amount of time on the agenda with crisp, focused data," he says. Tell physicians, 'If you don't like the way I'm presenting data at meetings, guide me in how I can give you better information for you to make the changes you need,'" he recommends.

If quality professionals are perceived as "outside the group" it is an uphill battle to get anything accomplished, says Rosenthal. He points to the hospital's recent initiative to reduce ICU infection rates. "If we had somebody from the quality management department who was simply assigned this, and was viewed as an outside person, it would have been much harder," he says.

[For more information, contact:

Alice G. Gosfield, Alice G. Gosfield and Associates, 2309 Delancey Place, Philadelphia, PA 19103. Phone: (215) 735-2384. Fax: (215) 735-4778. E-mail: agosfield@gosfield.com. Web: www.gosfield.com.

Donald L. Mellman, MD, MPH, MBA, FACHE, 1149 Shipwatch Circle, Tampa, FL 33602-5786. Fax: (813) 354-3623. E-mail: dmellman@post.harvard.edu.

Thomas Rosenthal, MD, Chief Medical Officer, UCLA Medical Center, 10833 Le Conte Avenue, Los Angeles, CA 90095. Phone: (310) 825-4686. E-mail: jrosenth@mednet.ucla.edu.

Katherine J. Wallace, RHIA, CPHQ, Director, Medical Quality Management, Columbus Regional Hospital, 2400 East 17th Street, Columbus, IN 47201. Phone: (812) 376-5676. Fax: (812) 376-5964. E-mail: kwallace@crh.org.

Jill White, RN CPHQ, Director, Performance Improvement and Case Management, Homestead Hospital, 975 Baptist Way, Homestead, FL 33033. Phone: (786) 243-8237. E-mail: JillW@baptisthealth.net.]