Which incentives will attract physicians to your QI initiatives?

Remember, salaried and independent doctors march to different beats

Rallying physicians around the quality improvement table is an evolving art. As hospitals buy group practices, quality managers are realizing that salaried physicians respond to different incentives than their community-based colleagues. QI pros who master the challenge do it by learning to put value-added features in their quality initiatives for both physician groups. If you haven’t mastered this already, it’s time to learn.

This task of finding dual-physician incentives won’t go away any time soon, says Roger Holloway, CEO of Kewanee (IL) Hospital. The sale of group practices to hospital systems reflects physicians’ desires to reduce their risk and increase their income, he explains. As managed care pressures impinge on physicians’ time and autonomy escalates, "it’s going to get a lot hotter," Holloway adds. In fact, the latest figures from the Chicago-based American Medical Association show that only 60% of physicians are in office-based practices, while 21% are hospital-based.1

There’s an added wrinkle for QI managers in integrated health care systems, which deal with salaried and community doctors. Each physician camp often believes that the other side has the better deal. Hobart Collins, management consultant with the Englewood, CO-based Medical Group Management Association, explains: The community side perceives hospital doctors as having more time for patients and greater access to funds for support staff and equipment. The hospital side perceives community physicians as having more autonomy.

Collins notes that salaried physicians do have one advantage that QI managers should consider. "If you’re asking physicians to serve on a quality task force, the salaried doctors are probably getting paid for it. But hospitals are going to have to compensate the community physicians for time in meetings or the extra record keeping," he cautions.

But the compensation doesn’t have to be about money. It can be about better patient care tools or deeper satisfaction of the individual physician’s professional values. Yes, it sounds like a nice theory, but with the right application of human relations skills, it works in the real world as well.

Watch your language

The first thing you want to do is avoid making either group the outsider. It can happen all too easily. "Be careful about what you consider right and wrong, and what’s different," says Mara Fellhoelter, director of quality and resource management at White Memorial Medical Center in Los Angeles. "Community doctors might practice differently, but sometimes their outcomes are no different. So be careful about your language when you’re describing care practices."

Another pitfall to avoid is the implied "our group vs. all the rest," she continues.

"Community doctors are sensitive to being singled out as they’ and hearing the hospital doctors referred to as we.’ Sometimes community docs can get to feeling they can’t do anything right."

While good patient care is the bottom line, each side gets there by a different route. Fellhoelter says she has discovered that pitching quality initiatives to several motivations at the same time is an effective way to generate support from both physician groups, as illustrated here:

o Common incentives unite hospital employees. "Employed physicians’ incentives are aligned with ours [hospital-based QI managers], and our futures are linked," she says. "We want to maintain our customer loyalty and make the doctors’ jobs easier so they can be productive."

Fellhoelter also reminds her physicians that as hospital employees, if they don’t get involved with systemwide quality programs early when they can help shape them, they’ll probably have to go along with something they didn’t plan.

o Altruism is alive. She says that altruism is a powerful motivator for community physicians who treat inner-city patients at White Memorial’s inpatient facility. They support strong inpatient education programs because they want their patients to understand their care and go home in the best shape possible.

o Community physicians need current information. Many are so busy seeing patients that they "don’t have a life," let alone time to keep current on clinical literature, observes Fellhoelter. Quality programs that provide collegial learning opportunities appeal to them. For example, she recently showed one doctor current clinical evidence to prove he did not need to order full-panel blood tests as often as he did. His response when Fellhoelter gave him copies of pertinent articles: "OK. I can do that." She also encourages the "incredibly current" hospital physicians to share clinical studies and care practice updates with their community-based peers.

o Comparative data convince naysayers. In efforts to engage a group practice that spurned invitations to help plan a critical path, Fellhoelter recalls, "We showed them their variance in utilization of inpatient resources, but they said it was just a coincidence. But the next time, they had almost no variance. And, they came to the table when we were planning the next critical pathway." (For additional tips on using comparative data as an incentive to participate in QI initiatives, see QI/TQM, May 1998, p. 66.)

When you have a choice between coercion or reciprocity with either physician group, take the latter. Cultivating reciprocity is what Fellhoelter calls the "soft side" of her job. "I see relationship management as a key part of my role." It takes time, and when we get busy, we can neglect it," she observes. But neglect has its risks.

She regularly invites doctors out to lunch, explaining she’s interested in learning what they need from the QI program. "Doctors see us as holding the utilization hat, and we have to teach them that we can help them," Fellhoelter says. For example, when she invited a cardiologist to lunch for the first time, the response was, "OK, Mara, what did I do wrong?" She points out that changing such perceptions can’t be done in your spare time.

Teaching newly affiliated physician practices how to comply with the Joint Commission on Accreditation of Health Care Organizations in Oakbrook Terrace, IL, accreditation for ambulatory care facilities is the QI manager’s responsibility in an integrated health system. Fellhoelter notes, "If your system purchases a clinic site 20 miles away, they’re out there practicing with your [hospital’s] name over their shingle. How can you vouch for the quality of that site unless you visit it and get to know the staff? I am constantly teaching doctors who come from private practice how to comply with the rules if they want to be operating under the hospital’s license."

Many doctors have virtually no comprehension of what’s involved in survey preparedness. As part of integrated health care organizations, for instance, group practices must meet criteria for patient and family education as well as human resource and information management. "Everything has to be in place, and they’re not used to that level of compliance," she says.

Rewards of being temperamentally correct

Beyond marketplace accountability lies another set of motivations rooted in the doctors’ core values. It’s the individual’s temperament that colors the way he or she practices medicine and conducts patient and co-worker relationships. Barbara Barron-Tieger, of West Hartford, CT-based Communication Consultants and co-author of The Art of SpeedReading People (Little, Brown & Company, Boston), explains that everyone has one of four basic temperaments. "There is a lot of variation within each of the four temperaments," she explains. "But if we can figure out what makes other people tick and pitch our ideas on their wavelengths, it helps us get our points across so they can hear. When you shift your pitch to appeal to each style of temperament, physicians will feel more open to it and more respected."

Barron-Tieger describes the four temperaments as follows:

1. Traditionalists like efficiency and clearly defined structure. They are comfortable with predictability and routine. Barron-Tieger notes, "When you want them to change, tell them why it’s going to make things better and more efficient."

2. Experiencers like immediate action. They appear casual and irreverent. They’re often playful. She advises, "Show them the short-term impact of change."

3. Conceptualizers like possibilities and the theoretical implications of QI initiatives. "They’re the ones in your group who like to focus on the big picture."

4. Idealists value relationships above all else. Often "artsy" in their dress, they want to use health care to make things better for people. "When you pitch a change, show them how it will have a positive impact on the whole person or whole organization."

(To learn more about temperamentally correct approaches, see related story, "70% of people fall into 2 of 4 temperament groups," p. 159.)


1. American Medical Association Center for Health Policy Research. Physician Characteristics and Distribution in the U.S. 1997-1998 ed. Chicago: American Medical Association; 1997.