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When establishing a patient care path system, often the No. 1 obstacle is getting hospital physicians to accept the idea of a protocol or pathway. Physicians play a key role, however, in making the pathway successful, says Maria Brillant, RN, coordinator of case management at New York University medical center in Brooklyn. "Communication is the biggest key to delivering effective care," she notes, and the process that leads to physician buy-in is good communication.
Instead of doing all the research themselves, case managers at Brillant’s facility have a philosophy of cooperation with physicians. "What we really try to do is find out what their ideas are as well, and then incorporate them or come up with a compromise," she explains.
Sometimes, the physician member of the pathway development team is not the physician who handles the highest volume of a particular procedure. That was the case when Brillant developed a joint replacement pathway in orthopedics. "The physician who ended up doing it the most kind of resented the fact, although we had solicited his input," she says. In that situation, Brillant had to be diplomatic. "Eventually I just said, Tell me how you want this written,’ and I wrote it that way. It’s a backdoor way of doing it. But that’s why we’re here — because there’s nothing we can’t do," she says. "We always believe that there’s a solution to every problem; there’s always an answer — sideways, backways, whatever way we can."
In her book, The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice, Toni G. Cesta, PhD, RN, FAAN, director of case management for Saint Vincents Hospital in New York City, suggests several valuable strategies for getting physicians on your side:1
• Involve physicians in the process of developing case management plans (CMPs) from the beginning. When assembling a team, Cesta says, it’s important to keep continuous quality improvement techniques in mind, choose a leader and a facilitator, and have six to eight team members. "I always say the leader should be a physician, because you’re really examining the practice patterns of physicians."
• Approach influential physicians who are interested in improving the quality of care and reducing the related cost for participation. You should pick a doctor who’s going to go out and "walk the walk," and be a champion for the care path. Someone who’s directly involved with the particular illness or procedure you’re addressing is the ideal candidate, Cesta adds, because his or her credibility in the field lends validity to your work.
• Share related published materials (e.g., evaluative research, description of case management systems, physicians’ opinions from other similar institutions) with all physicians. Brillant suggests calling upon drug reps and associations (like the American Heart Association) for literature that supports your pathway. Attend conferences, and review all the literature you can find, she says.
• Emphasize that CMPs are recommendations for treatment rather than rigid guidelines or standing orders. Make clear to all physicians that the CMP should be individualized for each patient on initiation and that changes are possible. "The misconception is that this is ready-made stuff," Brillant suggests. "Through the years, we have made [doctors] understand that we know they still have to vary sometimes, because no two patients are the same." The pathway is just a guideline, she stresses.
• Communicate how CMPs improve compliance with the standards of regulatory agencies. Many of the accrediting agencies and peer review organizations have the expectation that a health care organization will follow a standard of care; guidelines and care paths can help show that is being done, Cesta points out, because they are a sanctioned standard of care for the facility.
• Emphasize that the plans may be used as marketing tools to attract more participation from managed care organizations.
• Stress opportunities for research and creativity in patient care delivery. Cesta adds that especially when care paths are linked to outcomes measurement and analysis, physicians appreciate them more fully. They want to see evidence that quality of care has improved or will improve using the pathway. "Doctors respond better to outcomes-based care plans rather than time-based," she says.
Creativity is one of the best parts of being a case manager, Brillant agrees. "The challenge to your critical thinking is what the job is all about," she says, "and the reward is when you get everyone’s cooperation. It doesn’t happen overnight, but with persistence."
[For more information, contact:
Maria Brillant, RN, coordinator of case management, NYU Medical Center, 560 First Ave., New York, NY 10016. Telephone: (212) 263-7946.
Toni Cesta, PhD, RN, FAAN, Director of Case Management, Saint Vincent’s Hospital and Medical Center, New York, NY 10011. Telephone: (212) 604-7992.]
1. Cesta TG, Tahan HA., Fink LF. The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice. St. Louis: Mosby-Year Book Inc.; 1998.