What! No physician committees? Bucking status quo saves big bucks

There are better ways to disseminate information

Large hospitals can have two dozen or more single-specialty departments whose staffs meet monthly. Add to that up to 40 physician committees, most of which are charged with monitoring functions physicians are no longer required to monitor, and a hospital can incur hundreds of thousands of dollars in wasted physician and administrative time, and paper and copying costs annually, says Hugh Greeley, chairman of The Greeley Co., a firm specializing in medical staff re-engineering in Marblehead, MA.

Many of these meetings are unproductive, hampered by physicians’ reluctance to point out negatives in their colleagues’ practice patterns, or stalled by heated discussions of mundane or inconsequential matters. The data distributed at these meetings often is too much to digest, meaningless in the form in which it is presented, or not outcomes-oriented. Raw data from the lab or the pharmacy, for example, can be meaningless numbers that are merely passed along to executive or QI committees.

There’s got to be a better way, you say. But if we dare get rid of physician committees, what replaces them?

A handful of hospitals have begun replacing physician committees with cross-functional reporting teams. They’ve found they can eliminate most of the tedious minutes-taking and distribution, and still manage to improve information dissemination, not to mention saving several hundred thousand dollars annually. These hospitals’ managers say they don’t miss the paperwork, most of which was unread in any case, and that things are getting done a lot faster these days.

Myth: Physician committees required

It’s a shame physicians waste hours in need- less meetings when the Joint Commission on Accreditation of Healthcare Organizations requires hospitals to have only one physician committee — the medical staff executive committee.

Some hospitals are catching on. They’ve restructured physician departments and committees, harnessing the knowledge and power that was squandered in traditional meetings and funneling them into QI efforts. Physicians focus on care processes across disciplines and functions rather than within single specialties. They are provided with pertinent outcomes data and information that aid in process analysis. The new structure has lent credibility to quality improvement efforts, the managers at these hospitals say.

At The Methodist Hospital in Houston, for example, eight multispecialty committees replaced 28 single-specialty departments. While they’re still responsible for peer review of individual physicians, the eight new committees naturally gravitate toward complex cases and processes across the continuum of care because they include most specialists involved in the care, says Richard Harper, MD, chairman of the medical staff QM program and a neurosurgeon.

At a dozen Air Force hospitals across the country, functional work teams that complete a four-page form replaced medical staff committees that created reams of unused meeting minutes. One hospital saved more than $100,000 a year in copying costs alone, not to mention hundreds of hours of administrative and physician time, says Sarah Tackett, ART, BS, CPHQ, chief of professional staff management at the Air Force Material Command at Wright-Patterson Air Force Base in Dayton, OH, a kind of "corporate office" for the 12 health care facilities. The work teams report to multidisciplinary physician groups — similar to those at Methodist — that replaced single-specialty groups.

As the trend catches on, several other hospitals have re-engineered medical staffs to decrease bureaucracy, increase communication, and ensure quality patient care, Greeley says. (For other specific examples, see the related story on p. 19.)

Mixing up physicians and specialities

Valerie Purcell, RN, BSN, CPHQ, assistant manager of quality management, says of the 28 single-specialty QA committees at The Methodist Hospital, "There was lots of participation, but negligible results." Committee members rarely designed action plans or improved processes, she explains.

Frustrated hospital leaders replaced those peer review committees with eight multispecialty committees emphasizing quality management and reporting to the medical staff quality management committee. It wasn’t necessarily easy, and met with some physician resistance, Purcell reports, but now about 90 physicians meet monthly to develop ways of improving processes based on outcomes measurements Purcell’s department provides. (See article on p. 25 for list of new committees and advice on overcoming physician resistance.)

Representatives from hospital departments, such as pharmacy, laboratory, or social work, are invited to meetings when physicians need their input. The nature of the committee facilitates making decisions about processes, for example, when hand-offs should occur and whether treatments are appropriate and timely, Purcell says.

Purcell’s department provides data based on indicators and outcomes, using data garnered from the information system, utilization, and risk management departments; patient satisfaction surveys; an analysis of clinical pathway variances; and data gathered on blood transfusions, medication use, pathology, and intra- and inter-hospital transfers. For example, the QM department screens for all committees:

• mortality variances, such as deaths within 48 hours of surgery or within 24 hours of discharge from an intensive care unit (ICU);

• unplanned returns to OR within 48 hours;

• transfer from the catheter lab to OR;

• returns to the ICU within 24 hours;

• cardiac or respiratory arrest, myocardial infarction, or central nervous system complication within 48 hours postoperatively;

• adverse drug or transfusion reaction;

• readmissions to the hospital within seven days other than for chronic disease.

Specific committees receive information on specific populations of patients. Currently, Purcell explains, groups are looking at aggregate and physician-specific data on several diagnoses, including:

• thoracic-abdominal aortic aneurism surgery — types and rates of complications;

• coronary artery bypass — mortality rates risk-adjusted according to New York State Department of Health methodology, as well as outcomes of patients transferred into the hospital compared to other patients;

• cesarean and vaginal birth after cesarean (VBAC) rates;

• laparoscopic cholecystectomy — surgical-procedure-related outcomes;

• spinal surgery — the effectiveness of the surgical procedure and complication rate.

In the past year, physicians have initiated 27 practice improvement plans, 14 of which have been completed, Purcell says. Improvements have been made in pre-procedure assessment, documentation, and care delivery processes.

According to Harper, several procedures have seen decreases in mortality, morbidity, and length of stay as physician groups have examined "a long list of processes from top to bottom," including low back pain, ruptured disk, coronary artery bypass graft, hysterectomy, and cesarean.

But even more dramatic is that the hospital’s quality management program "has been acknowledged as a thorough, legitimate process," Harper says. "Multidisciplinary committees have increased the credibility of and respect for the QM process. In some hospitals, the QM committee is a paper tiger. Not here."

Saving forests and sanities

Air Force hospital physician committees reviewed blood use, surgical cases, medication use, medical records, risk management, credentialing, utilization, and infection control. When Tackett saw the volume of meeting minutes — foot-high stacks of papers — that went to the QA and medical staff executive committees, she was "convinced that the executive committee could not be reading all those minutes and therefore could not be making informed decisions on the quality of care within their facilities," she says.

While monitoring and improving these functions are crucial to hospital operations, the Joint Commission does not require physicians to do the monitoring and says summary reports can replace meeting minutes. Tackett formed a team that included each hospital’s medical staff chief to develop an alternative process. First, team members examined old minutes and found two major problems:

• Committee members often discussed irrelevant issues.

• Committees provided raw data that had little meaning. For example, the medication error rate included only that quarter’s data rather than a comparison along a longer time line. Numerator data lacked denominator data. For example, "number of cases with incomplete excision of malignancy" wasn’t compared against the total number of cases.

They decided the functions should be monitored by nonphysicians, who would forward the appropriate information directly to the medical staff executive committee. That way, Tackett says, the information would be more focused, the executive committee better informed, and physicians could spend more time with patients.

Subteams developed functional review forms for each function. (See copy of a sample form on pp. 21-24.) They consulted Joint Commission standards, internal experts like the chief of surgery, and outside consultants to determine forms’ content. Forms were field-tested for three months, then revised based on recommendations. Tackett asked for Joint Commission input on the forms before she formally piloted them. "They really liked the new process," she says. "All of our facilities are accredited, and surveyors seem to like it when they come in."

Each form begins with a mission statement to keep people focused on the issue at hand, Tackett explains. A facilitator for each function — usually someone with firsthand knowledge, like the pharmacy director for the medication use form or the lab director for the blood use form — is responsible for electronically completing and forwarding the form to the medical staff executive committee. Some of the Air Force hospitals have small work groups that meet to discuss the functions, Tackett says.

Tackett is pleased with the results of the new process, saying it saves "an enormous amount of administrative time and resources" and that the physicians report they are better informed now. "Doctors really like this process," she says.

Physician departments, which have been consolidated — like they were at The Methodist Hospital — into five broad teams, have electronic access to the forms, explains Donald Blada, MHA, BSN, director of performance improvement at the 28th Medical Group at Ellsworth Air Force Base, SD.

Using the forms, the medical staff executive committee and physician teams have been able to make improvements, Blada says. For example, when the executive committee found a sudden increase in infections on the third post-op day, the surgery team delved into the process and found a problem in instrument sterilization.

Ellsworth’s physician teams discuss each month the nine functions outlined by the Joint Commission. Between the new functional review process and the data they receive from Blada’s department, "they are totally focused on QI," Blada says.

[Editor’s note: For more information, contact: Valerie Purcell, Assistant Manager of Quality Management, The Methodist Hospital, 6565 Fannin, Houston, TX 77030-2707. Telephone: (713) 790-4621. Sarah Tackett, Chief of Professional Staff Management, Headquarters AFMC/SGPQ, 4225 Logistics Ave., Suite 23, Wright-Patterson AFB, Dayton, OH 45433. Telephone: (937) 656-3642. E-mail: tackets@wpgate1. wpafb.af.mil. Hugh Greeley, Chairman, The Greeley Co., P. O. Box 1168, Marblehead, MA 01945. Telephone: (800) 801-6661.]