Title: Medical Staff, Board and Hospital: Where the Rubber Hits th
1Medical 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
2- Alice G. Gosfield, JD
- Alice G. Gosfield and Associates, PC
- 2309 Delancey PlacePhiladelphia PA 19103(215)
735-2384 - Agosfield_at_gosfield.com
- www.gosfield.com
-
- James L. Reinertsen, MD
- The Reinertsen Group
- 375 East Aspen Meadow Lane
- Alta, WY 83414
- (307) 353-2294
- reinertsen_at_att.net
- www.reinertsengroup.com
3- Every system is perfectly designed to achieve
the results it gets. - Donald Berwick, M.D.
4- 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, mind-boggling
administrative waste, lack of access for a
significant number of Americans, and distrust and
dissatisfaction for virtually everyoneincluding
the key professionals who are needed to deliver
quality care.
5- 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
6(No Transcript)
7Every system is perfectly designed to produce
the results it gets.Berwick
8Hospital Mortality Rates vs Standardised
ReimbursementTop 10 and bottom 10 HSMR hospitals
USA
9SummaryThe Medical Staff Organization is part
of the hospital system that is producing these
results. If we want different results, its
likely that the Medical Staff will need to change
how it works, and what it does.
10The 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
11Tensions Among the Players
- Invasion of the body parts snatchers
- Defensive economic credentialing
- I dont see those kinds of people
- Hes got heads for the beds and knives for hire
- Its not my job to worry about this
- We are about market share and bottom line
12How 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
13External Mandates
- Medicare Conditions of Participation
- JCAHO deemed status
- State licensure rules
- HCQIA
14What 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
15Questions
- 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
- Dont hurt me mortality rate, ADEs, mishaps
-
16A 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
17If Physicians Cant 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
18Future Medical Staff Role Driving Quality
Then a miracle happens?
Current Medical Staff Role Marginalized
19Future Medical Staff Role Driving Quality
- Take a leadership stance
- Learn and use quality methods
- Practice the science of medicine as a team
Current Medical Staff Role Marginalized
20Principles 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
21Principles for physician leadership (2)
- Pay attention to process, not structure
- Do something real and meaningful take a risk
- Dont 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
22Levels of physician leadership in transforming
the Medical Staff
- Lead yourself
- Lead your organization
- Lead your profession
23Lead 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
24This 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
25Lead yourself Learn Quality Methods
- Read The Improvement Guide, Langley et al.,
Jossey Bass, 1996 - Enroll in Intermountain Health Cares 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
26Lead 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
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28The 2x2 Planning Matrix
ICU Admission
Yes
No
Yes
Comfort Care Only
No
29Reducing 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?
30More 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
31Where 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
32Lead 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 cant expect different results without a
change in some aspects of physician culture
33Why 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?
34- 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.
35- 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.
36A 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
37Questions 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 doesnt 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?
38Does practicing clinical science as a team make a
difference for patients?
39 Practicing science as a team CABG mortality at
BIDMC
40Does practicing clinical science as a team make
life better for physicians?
41A 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.
42Hospital Boards 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 hospitals 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.
43MD 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
44Summary
- Hospitals are under enormous pressure to produce
better results - The Medical Staff organization is a part of the
system producing the current results - We cant expect better results without changing
the system, including the Medical Staff - Medical Staff organizations cant do this alone
cooperation with Boards and Administrators will
be essential to success. - This would be goodreally goodfor the medical
profession, but most importantly, for our
patients.
45Resources
- 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/publicat
ions)
46More 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.ama-assn.org/ama1/pub/upload/mm/21/qual
ity_culture.pdf