Take these steps for noncompliant physicians

Work with, not against, physicians

When it comes to non-compliance by physicians for core measure requirements, quality professionals often feel powerless — they have plenty of data but not enough clout.

"This is a challenge nationally, and is not an issue related to one particular institution," says Gregg Meyer, MD, senior vice president for quality and safety at Massachusetts General Hospital in Boston. "The truth of the matter is, there is no one right approach or any magic bullet."

Here are steps to take to address this problem:

1. Start with the premise that, by and large, physicians want to do the right thing.

"If that's the case, then why is it we are not giving the right care and ordering the right medications with 100% reliability?" asks Meyer. One problem is general awareness — although many hospital administrators can probably cite the list of core measures right off the top of their heads, it's rare to find physicians, unless they spend a lot of their time focusing on quality, who can do the same, he says.

"Although some of the data have been out literally for decades, for example in terms of the importance of prescribing beta blockers for heart attacks, it takes a very long time to translate research into practice," says Meyer.

2. Acknowledge that physicians have limited resources.

Physicians may feel that they need to choose other priorities because these are more pressing needs than compliance with core measure requirements. "Physician may think there is something much more important to do," says Meyer. "At the end of the day it may be important for me to see that this patient gets pneumococcal vaccine, but I really need to focus my efforts to ensure that they don't need to be put on a ventilator."

3. Make it easy for physicians to comply.

"My sense is that we could really do a much better job than is generally done, to make it easy to do the right thing," says Meyer.

He suggests getting physicians onto computerized systems where they are prompted to make sure that a heart failure patient goes home on the right medications, or flagged to make it easy to see whether a patient has been vaccinated in the past.

"A lot of times, people fall into the trap of saying 'We need to do these things because they are core measure requirements and therefore we need physicians to do them,'" says Meyer. "But much of the time, it is actually teams and systems that are needed, and this should be an important focus for quality professionals."

Confront non-compliance

What if after all of these issues are addressed, a physician still does not comply, leading to poor compliance scores being publicly reported? "My experience is that this is a pretty rare event. This is not going to be a commonplace phenomenon," says Meyer. The first thing to do is to talk to the individual to understand the reason for their non-compliance, he advises.

"Sometimes you can learn some of the most valuable information from the person who is holding out, instead of saying they are a bad apple and we need to bend them to our will," he says.

In all likelihood, the physician truly believes that he or she is doing the right thing, just as staff who develop "workarounds" are trying to come up with a way of doing things more efficiently, says Meyer.

Core measure compliance is an issue that reflects whether the medical staff are engaged with the hospital around its quality agenda, says Alice Gosfield, a Philadelphia-based attorney and consultant specializing in quality improvement. "If you want to engage physicians on quality, focusing on 'core measures,' per se, likely won't get you there," she says. "That said, the issue becomes the nature of the defiance."

For instance, a physician may tell you that "I won't do it because I don't believe in the measure," which, in a facility that is really serious about quality, would raise an issue to be addressed as a serious matter to take into account in maintaining clinical privileges, says Gosfield. "But, if 50% of the medical staff are not there, then you have a very different set of problems, because your culture hasn't caught up with your rhetoric," she says.

Physicians may be resistant to relinquishing clinical autonomy to conform with evidence-based medicine, or view core measure protocols as "cookbook medicine," says Julia Slininger, quality improvement advisor for San Francisco-based Lumetra's Hospital Project Team. "In addition, there may be a gap between training on core measures and accountability," she adds.

If this is the case, use a "top down approach," with extensive leadership involvement from the board, CEO, or department chiefs. "On the floor, quality management staff, with the assistance of the nursing staff, can identify events of non-compliance and educate the physicians," advises Slininger. "Change bylaws to link performance in quality measures to reappointment."

Also, inform physicians that adherence to these measures will most likely in the future be linked to Medicare reimbursement with the Physician Quality Reporting Initiative. "Explain that it's beneficial to get on board now," says Slininger.

"Getting compliance with core measures has been a challenge, and one that we are proud to say we have tackled," says Denise Murphy, RN, MPH, CIC, vice president of safety and quality at Barnes-Jewish Hospital in St. Louis, MO. "That doesn't mean every one of our measure scores is perfect, but it means that our medical staff are committed to on-going improvement to achieve safe, high-quality care for our patients."

Early on in the process, clinical department chairs helped identify physicians whose research interests aligned with the hospital's performance improvement agenda. Clinical nursing directors identified patient safety champions among the ranks of the junior faculty and house staff.

"Through these search efforts, we identified a core group of physicians whose efforts and eventual success stories laid the foundation upon which we have built a larger pool of safety and quality leaders," says Murphy.

As a result, medical staff actively participate in performance improvement initiatives to tackle "broken" processes and lead teams for several clinical improvement initiatives. "They have helped create on-line education modules, altered processes, redesigned the structure of treatment rooms, standardized training, and even changed call schedules to improve patient outcomes," says Murphy. "We have improved every core measure since we began this aggressive PI work."

Acute myocardial infarction reperfusion times improved from less than 50% to 100%; timely pre-operative antibiotic delivery measures improved from 70% to 98%; and infection rates for ventilator-associated pneumonia are near zero for the hospital's six intensive care units.

"Much of this is related to physician partnerships in performance improvement," says Murphy.

Early in the process, a small group of cardiologists, emergency department physicians, and trauma surgeons agreed to learn Lean Engineering and Six Sigma concepts. These "early adopters" led the way through change once they saw how the study, redesign, and standardization of processes not only improved outcomes but streamlined their work.

That's an important realization, says Murphy, since non-compliance often is due to workload constraints.

When non-compliance does occur, the chief medical officer or a physician champion contacts the person involved, often using data or evidence from studies or guidelines, always with the focus on the organization's commitment to patients.

"We try to never use compliance with regulatory requirements as a reason for providing safe, high-quality care," says Murphy. "Physicians are more inclined to comply when they hear the evidence or rationale, and are approached in the spirit of wanting to do the right things for patients."

[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.

Gregg Meyer, MD, Senior Vice President, Quality and Safety, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114. Phone: (617) 724-8098. E-mail: gmeyer@partners.org.

Denise Murphy, RN, MPH, CIC, Vice President of Safety & Quality, Barnes-Jewish Hospital, 600 S. Taylor Ave., Suite 202, Mailstop # 90-94-204, St. Louis, MO 63110. E-mail: dmm1158@bjc.org.]