Work with physicians on core measures: Here's how

Some aspects of core measure compliance call for a "handshake" between quality professionals and physicians, says Christopher Sharp, MD, clinical assistant professor at Stanford (CA) University Medical Center. Here are the best ways to collaborate:

• Give prompt and accurate feedback.

Physicians need to have some kind of report on how they are actually doing, which needs to be both accurate and specific to the physician. "It also needs to be timely. If feedback comes long after the event occurred, it's hard for it to be utilized," says Sharp.

"Some institutions have even taken that to the point of concurrent feedback, which is probably ideal." With real-time intervention, if physicians haven't embarked on the right process step, it can be recognized and rectified almost immediately.

• Be sure your data can hold up to scrutiny.

It's certainly true that physicians respond to data, but it's equally true that they will always question the validity and robustness of the data, says Sharp. At Stanford, quality professionals make sure that quality data are "very robust," which almost always requires individual scrutiny of the extracted data, he says.

"You can use tools that pull data from billing codes and automated databases, but we have found it takes someone actually looking at the chart with at least an abstracting background if not a clinical background," says Sharp. "You want to be able to say, 'Aha! This patient should have been included in this measure and here is why.'"

Otherwise, these errors may be caught by physicians themselves, who don't like bad grades and will push back strongly if they feel the data are faulty.

You need to have physicians validating the content of the data you provide, and validating the way you give feedback to individuals.

"This is difficult to do in a 'silo,'" says Sharp. "The idea that a quality professional can influence physician behavior without having a physician be intimately a part of that process doesn't work."

At Stanford, a cadre of unit-based medical directors was created, with each physician assigned to a given unit to work directly with nurse managers on key quality issues, including core measures.

Quality professionals give the physician unit-specific data on core measure compliance, and it's then the physician's responsibility to look at the data and see how they can improve the process.

This approach is financially supported by the hospital, adds Sharp, in order to send a message that it's valuable enough to pay for a certain portion of the physician's time to do this. This makes the physician more accountable to the hospital for that time, more so than if they were doing it on a volunteer basis, says Sharp.

"Once the data are provided to them, it's theirs to act upon," says Sharp. "We have found that if we provide the data back to an individual on that level, it can be actionable, whereas if it is provided to an entire department, it is more diffuse."

• Work with physician champions to share best practices across units.

The cardiac unit may have very streamlined processes for cardiac measures, but the surgical care improvement project measures might get more focus in other units — yet, all these measures carry the same weight when reported. If a unit is struggling with compliance for a certain core measure, the quality professional acts as a liaison, working with physicians to bring best practices from other units, says Sharp. "A post-surgical unit will have different issues than a cardiac unit," he says.

• Designate specific individuals for each measure.

By having unit-based medical directors assigned specific core measure areas, the "go to" person for a given measure is clearly delineated, says Sharp. "That is something we didn't have before that we have always struggled with," he says. "This makes it very 'local' and allows you to enlist the help of a unit-based medical director, instead of going to the chief of staff yet again."

This way, quality professionals can go right to the champion to say, "We see that your unit is dragging with this measure. How can we help you? What are you not receiving from us that we can help you with?"

On several occupations, quality professionals have asked the champion to ferret out the reason for a certain physician's noncompliance. "Engaging a noncompliant physician is probably best done by another physician, who has the context and authority to approach that individual," Sharp says.

This allows for a frank conversation to take place, which may unearth surprising reasons for non-compliance, such as a physician's belief that a given patient should not be part of the guidelines. For example, the hospital has a population of patients who have had cardiac transplants, and there has been resistance around standardized procedures for vaccination for these patients —with valid reason.

"To get to the bottom of this required some peer to peer discussions," says Sharp. "In this unique population, any adverse event leads to a dramatic and tremendous workup." Physicians were aware that if their patient got a low-grade fever as a result of the vaccine, that would result in a slew of evaluations and tests.

"So we had to work with them to make sure that vaccination occurs before the patient is hospitalized," he says. "Further, if a cardiac transplant patient is significantly immunosuppressed, then they should not be falling into this measure. We have worked with our physicians to document this exclusion criterion, so that we win in this unique patient care population and the core measures."

• Try to see things from the physician's point of view.

While as a quality professional you would love to see 100% compliance for every core measure at your organization, the physician's goal is somewhat different, says Steven Tremain, MD, director of system redesign at Contra Costa (CA) Regional Medical Center. Simply put, the physician wants to do the best thing for the patient. Medicine cannot be reduced 100% of the time to protocols, emphasizes Tremain.

"What evidence-based medicine says is, the majority of patients will get the best care if we follow these steps. It doesn't say all patients," he says. "We are not looking for 100% compliance because that oversimplifies medicine."

However, physicians must document contraindications to allow for recognition of patients who can be excluded from core measures, stresses Tremain. "This also helps to identify physicians who need more coaching, and documents the need for 'push back' against certain core measures," he says.

He points to the controversy over the core measure requirement for antibiotics to be given within six hours of a pneumonia patient's arrival. (Initially, the measure required administration of antibiotics within four hours of presentation, but The Joint Commission increased the time frame to six hours after receiving complaints from the field. In addition, physicians are allowed to use a new data element, "diagnostic uncertainty," if the patient's diagnosis of pneumonia was not clear at arrival. Cases reflecting this data element will not be included in determining adherence to antibiotic timing standards.)

It is often impossible to determine whether the patient has pneumonia until eight hours after arrival or longer, says Tremain. To get 100% compliance with the previous requirement, physicians would be encouraged to give antibiotics for patients who wind up not having pneumonia, while overprescribing of antibiotics has been linked to hospital-acquired infections and "superbugs."

"This creates a monster. You can't tell if the patient has pneumonia, and so you end up giving a whole bunch of people antibiotics who don't need them," says Tremain. "That is what is happening across the country so people don't get dinged."

The goal should be to give antibiotics when the pneumonia is recognized and not before, says Tremain. "If we are not careful, we will end up treating the paper instead of the patient," he says.

A smaller group of physicians don't have valid concerns about core measure requirements and simply resent being told how to practice medicine. "Some physicians still say, 'This is my God-given right to make all of these decisions, I'm smarter than the rest of you and don't you dare tell me how to practice.' But the culture is changing. There is a new breed who want to practice scientifically based medicine. But we need to agree upon what the science says," says Tremain.

Bear in mind that core measures are a "huge culture change" for physicians, adds Tremain. "We've been telling doctors for 2,000 years that they know best, and now in the last few years, we are saying there are some things that ought to be more automatic because the science knows best," he says.

Tremain says that there is no question that core measures can improve care. "I have spent years leading this kind of change, but I think we have to be careful about how we do it," he says. "We want to make sure we push the right behavior. When all is said and done, we want to create a safer environment, not just look better on paper. It's all about the patient."

[For more information, contact:

Christopher Sharp, MD, Stanford Medical Group, 900 Blake Wilbur Dr., Room W2080, Palo Alto, CA 94304. Phone: (650) 723-6028. E-mail: sharpc@stanford.edu

Steven Tremain, MD, Director of System Redesign, Contra Costa Regional Medical Center, 2500 Alhambra Ave., Martinez, CA 94553. Phone: E-mail: stremain@hsd.cccounty.us

A White Paper on physicians and quality is available from the Institute of Healthcare Improvement free of charge. This resource includes tools to help hospital leaders create a written plan for physician engagement in quality and safety, and identify and prioritize initiatives for which physician engagement is essential. It can be accessed at http://www.ihi.org/IHI/Results/WhitePapers. Click on "Engaging Physicians in a Shared Quality Agenda."]