Critical Path Network: What to do if physicians dispute your data

How to present data effectively

It’s a frequent tactic of physicians: claiming that quality data are imperfect, invalid, or otherwise misleading.

"When physicians are not acting on proven data, the quality manager has to stand up to the physicians and protect the integrity of the data," says Frederick P. Meyerhoefer, MD, principal of the Canton, OH-based Meyerhoefer Organization, a consulting firm that specializes in compliance with Joint Commission on Accreditation of Healthcare Organizations standards.

"Physicians forget that they make decisions daily about their patients with clinical data that are frequently imperfect," he adds.

If you’re not able to analyze and present data effectively, physicians continually will challenge their validity, Meyerhoefer warns. "This will bog down the system with nitpicking rather than performing the needed analysis for patterns and trends and opportunities to improve," he says.

Here are effective tactics to use when physicians challenge your data:

• Give key physicians a heads-up before meetings.

It’s a good idea to brief committee chairs in advance about data you’ll be presenting at a meeting, Meyerhoefer advises. "It is also usually a good tactic to identify influential physicians and make them aware of the data and their import."

This way, physicians are aware of the implications of the data and you’ll avoid blindsiding them, he explains, adding that you also should consider briefing naysayer physicians in advance to head off potential obstacles, he suggests.

• Convince physicians to act on good data.

Physicians may be reluctant to take action even when the data are beyond reproach, Meyerhoefer says. In this case, you’ll want to avoid a full-blown confrontation, but you must urge physicians to act on the data, he advises.

For example, if data reveal that certain physicians are failing to discharge myocardial infarction patients on beta-blockers, intervention by the department chair and specific monitoring of the physicians might be called for. Or you might need to push physicians to implement a corrective action for the use of unapproved abbreviations and illegible handwriting monitoring.

If there is a physician with data with significant deviation from his or her peers, the presentation of that fact frequently is the only incentive needed to change behavior, Meyerhoefer notes. "No physician wants to be the sore thumb," he says.

You’ll need to instruct physicians on moving to the next "drill down," even when data indicate that a goal has been reached, Meyerhoefer says. For example, if a goal for 90% compliance has been reached, physicians need to look intensively at the noncompliant 10% of the data to identify correctable factors.

"The quality manager must be the goad to move ahead for further quality improvement in patient care and decrease the 10% variance," he notes.

• Be proactive if physicians lack confidence.

"Physicians are very data-driven," says Tania V. Bridgeman, PhD, RN, director of clinical pathway development at University of California — Irvine. "If they get flawed data one time, it is a very long recovery period before they are comfortable again."

For example, a physician might ask for data on a certain procedure, but the wrong ICD-9 code is queried. "Once they see something like that, their confidence level drops. So all your homework must be done with no bases left uncovered — they will find them."

If a physician contends that poor-quality data have been received from one of your team members, your instinct might be to downplay the individual in question to avoid conflict, but this is a mistake, Bridgeman says. Instead, she recommends bringing the person to individual meetings to regain confidence.

"If a physician doesn’t believe in the integrity of data from finance or another hospitalwide clinical database because they’ve been burned in the past, I bring those key people in," she says. "You don’t put them in the background — you place them out front."

For example, the facility’s spine surgeon said he had received some flawed data from the decision-support analyst, so Bridgeman brought that person to a meeting with the physician so she could address the problem directly.

"Every time I went to meet with him, she became an integral part of the meeting. I didn’t go away; I continued to return with this person to the same physician over and over again," she says. "It gradually built up the confidence level."

Bridgeman attributes this to having "relentless follow-through. If I said we were coming back with data in two weeks, we went back in two weeks and I gave the floor to the person they had some trepidation about," she says.

• Identify physician champions.

Enlist the help of individuals who strive for clinical excellence and are not afraid to address issues with other physicians, Bridgeman says. When she developed a clinical algorithm for abdominal pain, she sensed resistance from the entire emergency department (ED).

"They didn’t want to follow a predetermined algorithm and also be asked to access an electronic order set that would activate the pathway," she recalls. "I took the physician champion with me. What I wasn’t able to address as a nurse, he was able to address. Ultimately, the ED chief joined forces with the champion."

If problems occur with resistant physicians, the champion can help with that problem as well, Bridgeman says. "If you find that people are slacking off from using the pathway, then the champion would come in behind you and help with the reeducation process to achieve compliance," she says.

She says that the "physician champion" strategy has made quality projects a success several times at her facility. For example, it was determined pneumonia patients admitted through the ED sometimes were having blood cultures drawn after antibiotics were administered, instead of beforehand.

"This null and voids the blood culture," explains Bridgeman.

She used the facility’s clinical documentation system to pull the records of 35 pneumonia patients and discovered that the problem was occurring 27% of the time.

The cause was due to a communication breakdown in the transfer between the ED and the inpatient nursing unit, says Bridgeman. "There was an assumption that antibiotics had not been given, when they actually had been given in the ED," she explains.

As a result, a systemwide educational process was implemented, with the champion physician and the chief of the department of medicine going to grand rounds to educate the residents. "We also educated all nursing units again on the importance of this," Bridgeman says.

Similarly, physician buy-in was integral when a quality issue arose regarding blood transfusions. "When we found the benchmark for blood transfusions was approximately 30% and we were at 60%, we initiated an action plan for an in-depth look at what was going on," she says. "The re-transfusion of autologous blood is pervasive across the United States."

In this case, Bridgeman worked with the physician champion to get the chief of the department of orthopedics and chief of pathology on board. A performance team met and determined that the facility’s intraoperative cell saver required a pump technician to operate, who wasn’t always available. "So we purchased a smaller machine that transfused both on the OR and the PAR [post-anesthesia recovery], and continued to transfuse on the unit," she says. The equipment collects up to 1,000 cc blood, which is cleansed and re-transfused. The autologous rate of transfusions now are dropping, in accordance with the national benchmark.

• Ask physicians for input.

Don’t hesitate to ask physicians directly for their help, Bridgeman advises. "A plea for assistance enhances their credibility and thus elicits their support," she says.

Physician leaders typically have access to databases and a network of colleagues to consult with, and in turn, will offer the information to you, she says. When you appeal for physician input, emphasize that your facility is comparing unfavorably with others, Bridgeman suggests. For example, say, "Look at where we stand against other university medical centers — we’ve got to change this.

"You have to tell them, I am really in trouble and can’t get to the bottom of this. I need your help and expertise,’" she adds. "All of a sudden, they feel part of the process because you are asking for their help."