AMA-OMSS.052903.fnl

Report
Medical Staff, Board and
Hospital: Where the Rubber Hits
the Road in the Quest for
Quality
Alice G. Gosfield, JD
James L Reinertsen, MD
June 14, 2003
Alice G. Gosfield, JD
Alice G. Gosfield and
Associates, PC
2309 Delancey Place
Philadelphia PA 19103
(215) 735-2384
[email protected]
www.gosfield.com
James L. Reinertsen, MD
The Reinertsen Group
375 East Aspen Meadow
Lane
Alta, WY 83414
(307) 353-2294
[email protected]
www.reinertsengroup.com
“Every system is perfectly
designed to achieve the
results it gets.”
Donald Berwick, M.D.
The American health care system is
perfectly designed to produce dazzling
technologies, large numbers of
exceptionally well-trained doctors, very
high costs, serious safety risks, underuse,
overuse, and misuse of resources, mindboggling administrative waste, lack of
access for a significant number of
Americans, and distrust and dissatisfaction
for virtually everyone—including the key
professionals who are needed to
deliver quality care.
Perhaps the most troublesome
piece of data from the past 3
years…
More than 40% of nurses
surveyed would not feel
comfortable having a family
member or loved one cared for
in the facility where they
worked.
American Nurses Association, 2001
“Every system is
perfectly designed to
produce the results it
gets.”
Berwick
Hospital Mortality Rates vs
Standardised Reimbursement
Top 10 and bottom 10 HSMR hospitals
200
180
160
140
120
100
80
60
40
20
0
USA
$0
$5,000
$10,000
$15,000
Summary:
The Medical Staff Organization
is part of the hospital “system”
that is producing these results.
If we want different results, it’s
likely that the Medical Staff will
need to change how it works,
and what it does.
The Hospital Quality Mandate
Crossing the Quality Chasm
Leapfrog
Commercial Report Cards
Government Report Cards
Data to Consumers: Healthgrades.com,
DoctorQuality.com, US News and World
Report, Hospital Mortality Rates…
Tensions Among the Players
Invasion of the body parts snatchers
Defensive economic credentialing
“I don’t see those kinds of people”
“He’s got heads for the beds and knives
for hire”
“It’s not my job to worry about this”
“We are about market share and bottom
line”
How the Medical Staff Plays Today
Self-governed, autonomized and excluded
from real power
Individualized credentialing
Barely true review for privileges: only for
serial maimers
Avoidance of NPDB reports: “there but for
the grace of God go I”
Difficult to get a quorum at Medical Staff
meetings
External Mandates
Medicare Conditions of Participation
JCAHO: “deemed status”
State licensure rules
HCQIA
What absorbs the Medical Staff
today?
Economic credentialing
EMTALA on call obligations
Using NPPs
Cross departmental privileges (i.e., clinical
turf)
Board, Administration, and Medical Staff
communication failures
Questions
Are these the highest and best uses of the
Medical Staff?
Do any of these activities have a
meaningful impact on the most important
things patients expect when they come
into a hospital?
– Cure me: outcomes
– Heal me: patient satisfaction
– Don’t hurt me: mortality rate, ADE’s, mishaps
A Better Role for the Medical Staff
Become the primary driver of quality of
care in the hospital, and the community
Take aim at major issues such as mortality
rates, patient safety, nurse staffing, and
professional quality of life
Accept accountability as a medical staff for
the results of the hospital as a care system
If Physicians Can’t Do This, Who Can?
Plenary licensure
Portal to the rest of the system
The essence of physician-patient
relationship: explain, predict and change
The need for time and touch as a quality
concern
Future
Medical Staff
Role: Driving
Quality
Then a
miracle
happens…?
Current
Medical Staff
Role:
Marginalized
•Take a
leadership
stance
•Learn and
use quality
methods
•Practice the
science of
medicine as
a team
Current
Medical Staff
Role:
Marginalized
Future
Medical Staff
Role: Driving
Quality
Principles for physician leadership
Involve physicians at the earliest stages of
initiatives that will affect them
Identify the real leaders: not always the
one with the crown and scepter
Build trust: Do what you say, say what you
do consistently over time
Communicate openly, frequently, candidly
Be willing to be held accountable for
participation
Principles for physician leadership
(2)
Pay attention to process, not structure
Do something real and meaningful: take a
risk
Don’t let one loud negative voice stop you
Work across boundaries: you need
administrators, and they need you
Start by defining reality, using data, on a
small scale, about something important
Levels of physician leadership in
transforming the Medical Staff
Lead yourself
Lead your organization
Lead your profession
Lead Yourself: Get in Motion
Read “Crossing the Quality Chasm”
Talk to your patients and employers
about how they see your practice
Personally interview some nurses and
doctors involved in a recent, serious
harmful event
Commit: voluntary, public, permanent
This is the true joy in life, to be
used for a purpose you consider a
mighty one, to be a force of nature,
rather than a feverish, selfish clod
of ailments and grievances
complaining that the world will not
devote itself to making you happy.
G.B. Shaw
Lead yourself: Learn Quality Methods
Read The Improvement Guide, Langley et al.,
Jossey Bass, 1996
Enroll in Intermountain Health Care’s ATP
Program
Go to the IHI Annual Forum, December 2-5,
2003, New Orleans
Start a rapid cycle of improvement in something
important in your own practice e.g. touch time
Lead Your Organization
Gather some data about performance on
something important e.g. review the last
50 consecutive deaths at your hospital
Ask the Board to adopt a serious goal for
improvement of mortality rates
Work with Administration to take action on
what you learn about patterns of deaths in
your hospital
– Teamwork, Nurse Staffing, Coordination of
Care, Adverse Events, ICU organization…
Looking Under the Hood:
50 Consecutive Deaths in 27 hospitals
ICU Admission
No ICU Admission
Comfort Care
40/1350
179/1350
3.0%
13.3%
(0-14%)
(0-40%)
548/1350
583/1350
40.6%
43.2%
(16-64%)
(18-64%)
Non Comfort Care
The 2x2 Planning Matrix
ICU Admission
Yes
Comfort
Care
Only
No
Yes
No
Develop and execute a Develop alternatives to
“policy” limiting use of
hospitalization
ICU for comfort care
Use best practices in
only
End of Life care
Increase capability for
comfort care on the
patient care units
Responsiveness to nurse
ICU redesign: closed
Better communication and
units, bundles, daily
planning
goals sheet,
Pre-code team, hospitalists
multidisciplinary
Reduction of adverse
rounds…
events
Reducing mortality: what the
Medical Staff could do
Standardize, simplify common hazardous
processes
– PCA drips: from 40 solutions to 4, from 4
devices to 1
– Narcotics: automatic substitution for Demerol
orders
– Standing order sets: “start heparin”
Credential teams based on evidence:
– ICUs: who should be taking care of critically ill
patients?
More on mortality: what the medical
staff might do
Implement “operating systems”
– Ventilator bundle: 5 actions for every
ventilated patient, reduce mortality up to 30%
– Wound infection bundle: 6 actions for every
operated patient, reduce infections up to 60%
Promote a culture of responsiveness to
nurses’ concerns, teamwork,
communication
Where will you find the time for
these Medical Staff activities?
Contract out pieces of corrective
action including fair hearings
Use the Stark regulation to get help
from the hospital (make compliance
clinically relevant)
Standardize and simplify your clinical
work
Lead Your Profession
Medical Staff organizations have viewed
the practice of medicine as an individual
endeavor, rather than a team activity
This professional viewpoint is part of the
“system that is perfectly designed to
produce the results it gets.”
You can’t expect different results without a
change in some aspects of physician
culture
Why have physicians lost
autonomy?
Failure of the many to clean up the
messes of the few
Fading political power, as more
physicians put self-interest above
patient interest
Not practicing the art of medicine
Not practicing the science?
We are losing our clinical
autonomy in part because the
public has learned that the
basis for it, the full power of
our scientific knowledge, is not
being consistently applied for
their benefit.
PHYSICIAN CULTURE
We regularly engage in vigorous conversations
about clinical evidence with our colleagues.
But we seldom enter into those
conversations with the clear understanding
that any conclusions we reach will be
translated into a system of standing orders,
reminders, measurements, feedback loops,
and other steps to implement any
consensus that emerges from the dialogue.
A paradox: more individual
autonomy means less professional
autonomy
We talk about evidence in groups
We implement it as individuals
The resulting variation looks like the Tower of
Babel, to our nurses and pharmacists.
Our results fall short of what we and our
patients want
Society acts to reduce our professional
autonomy
Questions for your Medical Staff
Beyond sterile technique in the OR, could you
agree on evidence-based practices that should
be done for a particular diagnosis or procedure
for every patient, even if a doctor doesn’t order
them?
If you reached agreement on a list of these
“operating systems,” how would you make
sure that they are done, reliably?
How would incorporate new evidence into
these operating systems?
Does practicing
clinical science as a
team make a
difference for
patients?
Oct 99-Oct 01
ct
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g
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n
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b
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c
ct
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Au
g
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n
Ap
r
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16 Evidence-based
Processes Standardized
Jan-Apr 01
De
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9
8
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6
5
4
3
2
1
0
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% Mortality
Practicing science as a team:
CABG mortality at BIDMC
Does practicing
clinical science as a
team make life better
for physicians?
A working hypothesis for physician
leaders
If we practice the science of
medicine as teams, society might
give us the privilege of practicing
the art of medicine as individuals.
By sharing individual autonomy in
the science, we can regain
professional autonomy, and
rediscover precious touch time.
Hospital Board’s Role in Quality:
Setting Aims, Building Will
Understand the important things the community
expects from your hospital.
See that a few system-level measures of those things
are established, understood, and monitored (the “Big
Dots.”)
Aim to improve the Big Dots, and link the improvement
of those things to your main strategic goals.
Build the hospital’s will to achieve these aims.
Maintain constancy of purpose for the long-term quality
transformation of the hospital.
Promote collaboration across the community for
redesign of care.
MD and Administrator Roles in Quality:
Generating Ideas, Executing Change e.g.
Establish safe levels of nurse staffing, and give
nurses a large measure of control of their
practice environment.
Establish an environment that fosters
professional teamwork between doctors and
nurses.
Manage hospital flow so that the right patients
are put on the right units at the right time.
Apply the known evidence to care: team
rounds, ventilator bundles, order sets…
Use Improvement Science in daily work
Summary
Hospitals are under enormous pressure to
produce better results
The Medical Staff organization is a part of the
“system” producing the current results
We can’t expect better results without changing
the system, including the Medical Staff
Medical Staff organizations can’t do this alone:
cooperation with Boards and Administrators will
be essential to success.
This would be good—really good—for the
medical profession, but most importantly, for our
patients.
Resources
Reinertsen, “Zen and the Art of Autonomy
Maintenance”, Annals of Internal Medicine, June
17, 2003 (in press)
Gosfield, “Whither Medical Staffs?: Rethinking
the Role of the Staff in the New Quality Era”,
HEALTH LAW HANDBOOK, (A. Gosfield, ed.,
2003) pp.141-217, available at
www.gosfield.com/publications)
More Resources
Reinertsen, Boards, Administrators, Medical
Staffs and Quality: Sorting Out the Roles
Trustee, (September, 2003, in press)
Gosfield, “Quality and Clinical Culture: The
Critical Role of Physicians in Accountable Health
Care Organizations,” AMA, 1998,
http://www.amaassn.org/ama1/pub/upload/mm/21/quality_cultur
e.pdf

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