User login
Hospitalists Poised to Advance Health Care Through Teamwork
The problems that ail the American health-care system are numerous, complex, and interrelated. In writing about how to fix our chronically dysfunctional system, Hoffman and Emanuel recently cautioned that single solutions will not be effective.1 In their estimation, “individually implemented changes are divisive rather than unifying,” and “the cure … to this complex problem … will require a multimodal approach with a focus on re-engineering the entire care delivery process.”
If single solutions are insufficient (or even counterproductive and divisive), health care’s key stakeholders must figure out how to work more effectively together. In a nutshell, effective collaboration is critical. Those who collaborate well will thrive in the future, while those who are unable to break down silos to innovatively engage their patients, colleagues, and communities will fail.
Our Tradition of Teamwork
Hospitalists understand the importance of collaboration, as teamwork has been a fundamental value of our specialty since its inception. We have a rich tradition of creating novel, collaborative working relationships with a diverse group of key stakeholders that includes primary-care providers (PCPs), nurses, subspecialists, surgeons, case managers, social workers, nursing homes, transitional-care units, home health agencies, hospice programs, and hospital administrators. We have created innovative, collaborative strategies to effectively and safely comanage patients with other physicians, navigate care transitions, and integrate the input of the many people required to manage day-to-day hospital care.
These experiences will serve us well in a future in which collaboration is essential. We should plan to share our expertise in creating effective teams by assuming leadership roles within our institutions as they implement collaborative initiatives on a larger scale through such concepts as the accountable-care organization (ACO).
We should furthermore plan to seek out new, collaborative opportunities by identifying novel agendas to champion. Two critically important, novel agendas for hospitalists to advance are:
- Enhanced physician-patient collaboration; and
- Collaboration to share and propagate new innovation among hospitalists and HM programs across the country.
True Collaboration with Patients
In my last column, I wrote about how enhancing the patient experience of care will have far-reaching, positive effects on health-care reform.2 Attending to the patient experience has been proven to enhance patient satisfaction, care quality, and care affordability. Initiatives to enhance care experience thus hold promise as global, Triple Aim (better health and better care at lower cost) effectors.
The key to improving patient experience is patient engagement, and the key to patient engagement is incorporating patient expectations into the care planning process. The question thus becomes, “How do physicians identify and appropriately act on patient expectations?” The answer is by collaborating with patients to arrive at care decisions that respect their interests. Care providers must work together with patients to create care plans that respect patient preferences, values, and goals. This will require shared decision-making characterized by collaborative discussions that help patients decide between multiple acceptable health-care choices in accordance with their expectations.
SHM is commissioning a Patient Experience Advisory Board to identify how the society can support its members to effectively collaborate with patients and their loved ones. Expect in the near future to learn more from SHM about how to truly engage your patients to enhance the value of the care you deliver.
The Commodification of Health-Care Quality and Affordability
I recently learned of a subspecialty group that had created a new clinical protocol that promised to deliver higher-quality, more affordable care to their patients. When asked if they would share this with physicians outside of their own group, they flat-out refused. What would motivate a physician group to refuse to collaborate with their community to propagate a new innovation that promises to enhance the value of health care? The answer may lie with an economic concept known as commodification.
Commodification is the process by which an item that possesses no economic interest is assigned monetary worth, and hence how economic values can replace social values that previously governed how the item was treated. Commodification describes a transformation of relationships formerly untainted by commerce into commercial relationships that are influenced by monetary interests.
As payors move away from reimbursing providers simply for performing services (volume-based purchasing) to paying them for the value they deliver (value-based purchasing), we must acknowledge that we are “commodifying” health-care quality and affordability. By doing so, the economic viability of medical practices and health-care institutions will depend on delivering value, and to the extent that this determines a competitive advantage in the marketplace, providers might be reluctant to share innovations in quality and affordability.
We must not let this happen to health care. Competing on the ability to effectively deploy and manage new innovations to enhance quality and affordability is acceptable. Competing, however, on the access to these innovations is ethically unacceptable for an industry that is indispensable to the health and well-being of its consumers.
Coke and Pepsi do not provide indispensable products to society. It is thus fine for soft-drink makers to keep their recipes top secret and fight vigorously to prevent others from gaining access to their innovations. Health-care providers, however, cannot morally defend refusing to share new products and processes that decrease costs, improve patient experience, decrease morbidity, prolong life, or otherwise enhance quality.
We must, therefore, strive to continuously collaborate with our hospitalist colleagues and HM programs across the country to propagate new innovation. When someone builds a better mouse trap, it should be shared freely so that all patients have the opportunity to benefit. We must not let the pursuit of economic competitive advantage prevent us from collaborating and sharing ideas on how to make our health-care system better.
Conclusion
Fixing health care is complicated, and employing collaboration in order to do so will be required. Hospitalists have vast experience in working effectively with others, and should leverage this experience to lead the charge on efforts to enhance physician-patient collaboration. Hospitalists should strive to continuously collaborate with their colleagues to ensure open access to new discoveries that improve health-care quality and affordability. Those interested in learning more about how to be successful collaborators might find it helpful to seek out additional resources on the subject. Collaboration, by Morten T. Hansen, is a good source on how to turn this concept into action.3
References
- Hoffman A, Emanuel E. Reengineering US health care. JAMA. 2013;309(7):661-662.
- Frost, S. A matter of perspective: deconstructing satisfaction measurements by focusing on patient goals. The Hospitalist. 2013:17(3):59.
- Hansen M. Collaboration: how leaders avoid the traps, create unity, and reap big results. Boston: Harvard Business Press; 2009.
The problems that ail the American health-care system are numerous, complex, and interrelated. In writing about how to fix our chronically dysfunctional system, Hoffman and Emanuel recently cautioned that single solutions will not be effective.1 In their estimation, “individually implemented changes are divisive rather than unifying,” and “the cure … to this complex problem … will require a multimodal approach with a focus on re-engineering the entire care delivery process.”
If single solutions are insufficient (or even counterproductive and divisive), health care’s key stakeholders must figure out how to work more effectively together. In a nutshell, effective collaboration is critical. Those who collaborate well will thrive in the future, while those who are unable to break down silos to innovatively engage their patients, colleagues, and communities will fail.
Our Tradition of Teamwork
Hospitalists understand the importance of collaboration, as teamwork has been a fundamental value of our specialty since its inception. We have a rich tradition of creating novel, collaborative working relationships with a diverse group of key stakeholders that includes primary-care providers (PCPs), nurses, subspecialists, surgeons, case managers, social workers, nursing homes, transitional-care units, home health agencies, hospice programs, and hospital administrators. We have created innovative, collaborative strategies to effectively and safely comanage patients with other physicians, navigate care transitions, and integrate the input of the many people required to manage day-to-day hospital care.
These experiences will serve us well in a future in which collaboration is essential. We should plan to share our expertise in creating effective teams by assuming leadership roles within our institutions as they implement collaborative initiatives on a larger scale through such concepts as the accountable-care organization (ACO).
We should furthermore plan to seek out new, collaborative opportunities by identifying novel agendas to champion. Two critically important, novel agendas for hospitalists to advance are:
- Enhanced physician-patient collaboration; and
- Collaboration to share and propagate new innovation among hospitalists and HM programs across the country.
True Collaboration with Patients
In my last column, I wrote about how enhancing the patient experience of care will have far-reaching, positive effects on health-care reform.2 Attending to the patient experience has been proven to enhance patient satisfaction, care quality, and care affordability. Initiatives to enhance care experience thus hold promise as global, Triple Aim (better health and better care at lower cost) effectors.
The key to improving patient experience is patient engagement, and the key to patient engagement is incorporating patient expectations into the care planning process. The question thus becomes, “How do physicians identify and appropriately act on patient expectations?” The answer is by collaborating with patients to arrive at care decisions that respect their interests. Care providers must work together with patients to create care plans that respect patient preferences, values, and goals. This will require shared decision-making characterized by collaborative discussions that help patients decide between multiple acceptable health-care choices in accordance with their expectations.
SHM is commissioning a Patient Experience Advisory Board to identify how the society can support its members to effectively collaborate with patients and their loved ones. Expect in the near future to learn more from SHM about how to truly engage your patients to enhance the value of the care you deliver.
The Commodification of Health-Care Quality and Affordability
I recently learned of a subspecialty group that had created a new clinical protocol that promised to deliver higher-quality, more affordable care to their patients. When asked if they would share this with physicians outside of their own group, they flat-out refused. What would motivate a physician group to refuse to collaborate with their community to propagate a new innovation that promises to enhance the value of health care? The answer may lie with an economic concept known as commodification.
Commodification is the process by which an item that possesses no economic interest is assigned monetary worth, and hence how economic values can replace social values that previously governed how the item was treated. Commodification describes a transformation of relationships formerly untainted by commerce into commercial relationships that are influenced by monetary interests.
As payors move away from reimbursing providers simply for performing services (volume-based purchasing) to paying them for the value they deliver (value-based purchasing), we must acknowledge that we are “commodifying” health-care quality and affordability. By doing so, the economic viability of medical practices and health-care institutions will depend on delivering value, and to the extent that this determines a competitive advantage in the marketplace, providers might be reluctant to share innovations in quality and affordability.
We must not let this happen to health care. Competing on the ability to effectively deploy and manage new innovations to enhance quality and affordability is acceptable. Competing, however, on the access to these innovations is ethically unacceptable for an industry that is indispensable to the health and well-being of its consumers.
Coke and Pepsi do not provide indispensable products to society. It is thus fine for soft-drink makers to keep their recipes top secret and fight vigorously to prevent others from gaining access to their innovations. Health-care providers, however, cannot morally defend refusing to share new products and processes that decrease costs, improve patient experience, decrease morbidity, prolong life, or otherwise enhance quality.
We must, therefore, strive to continuously collaborate with our hospitalist colleagues and HM programs across the country to propagate new innovation. When someone builds a better mouse trap, it should be shared freely so that all patients have the opportunity to benefit. We must not let the pursuit of economic competitive advantage prevent us from collaborating and sharing ideas on how to make our health-care system better.
Conclusion
Fixing health care is complicated, and employing collaboration in order to do so will be required. Hospitalists have vast experience in working effectively with others, and should leverage this experience to lead the charge on efforts to enhance physician-patient collaboration. Hospitalists should strive to continuously collaborate with their colleagues to ensure open access to new discoveries that improve health-care quality and affordability. Those interested in learning more about how to be successful collaborators might find it helpful to seek out additional resources on the subject. Collaboration, by Morten T. Hansen, is a good source on how to turn this concept into action.3
References
- Hoffman A, Emanuel E. Reengineering US health care. JAMA. 2013;309(7):661-662.
- Frost, S. A matter of perspective: deconstructing satisfaction measurements by focusing on patient goals. The Hospitalist. 2013:17(3):59.
- Hansen M. Collaboration: how leaders avoid the traps, create unity, and reap big results. Boston: Harvard Business Press; 2009.
The problems that ail the American health-care system are numerous, complex, and interrelated. In writing about how to fix our chronically dysfunctional system, Hoffman and Emanuel recently cautioned that single solutions will not be effective.1 In their estimation, “individually implemented changes are divisive rather than unifying,” and “the cure … to this complex problem … will require a multimodal approach with a focus on re-engineering the entire care delivery process.”
If single solutions are insufficient (or even counterproductive and divisive), health care’s key stakeholders must figure out how to work more effectively together. In a nutshell, effective collaboration is critical. Those who collaborate well will thrive in the future, while those who are unable to break down silos to innovatively engage their patients, colleagues, and communities will fail.
Our Tradition of Teamwork
Hospitalists understand the importance of collaboration, as teamwork has been a fundamental value of our specialty since its inception. We have a rich tradition of creating novel, collaborative working relationships with a diverse group of key stakeholders that includes primary-care providers (PCPs), nurses, subspecialists, surgeons, case managers, social workers, nursing homes, transitional-care units, home health agencies, hospice programs, and hospital administrators. We have created innovative, collaborative strategies to effectively and safely comanage patients with other physicians, navigate care transitions, and integrate the input of the many people required to manage day-to-day hospital care.
These experiences will serve us well in a future in which collaboration is essential. We should plan to share our expertise in creating effective teams by assuming leadership roles within our institutions as they implement collaborative initiatives on a larger scale through such concepts as the accountable-care organization (ACO).
We should furthermore plan to seek out new, collaborative opportunities by identifying novel agendas to champion. Two critically important, novel agendas for hospitalists to advance are:
- Enhanced physician-patient collaboration; and
- Collaboration to share and propagate new innovation among hospitalists and HM programs across the country.
True Collaboration with Patients
In my last column, I wrote about how enhancing the patient experience of care will have far-reaching, positive effects on health-care reform.2 Attending to the patient experience has been proven to enhance patient satisfaction, care quality, and care affordability. Initiatives to enhance care experience thus hold promise as global, Triple Aim (better health and better care at lower cost) effectors.
The key to improving patient experience is patient engagement, and the key to patient engagement is incorporating patient expectations into the care planning process. The question thus becomes, “How do physicians identify and appropriately act on patient expectations?” The answer is by collaborating with patients to arrive at care decisions that respect their interests. Care providers must work together with patients to create care plans that respect patient preferences, values, and goals. This will require shared decision-making characterized by collaborative discussions that help patients decide between multiple acceptable health-care choices in accordance with their expectations.
SHM is commissioning a Patient Experience Advisory Board to identify how the society can support its members to effectively collaborate with patients and their loved ones. Expect in the near future to learn more from SHM about how to truly engage your patients to enhance the value of the care you deliver.
The Commodification of Health-Care Quality and Affordability
I recently learned of a subspecialty group that had created a new clinical protocol that promised to deliver higher-quality, more affordable care to their patients. When asked if they would share this with physicians outside of their own group, they flat-out refused. What would motivate a physician group to refuse to collaborate with their community to propagate a new innovation that promises to enhance the value of health care? The answer may lie with an economic concept known as commodification.
Commodification is the process by which an item that possesses no economic interest is assigned monetary worth, and hence how economic values can replace social values that previously governed how the item was treated. Commodification describes a transformation of relationships formerly untainted by commerce into commercial relationships that are influenced by monetary interests.
As payors move away from reimbursing providers simply for performing services (volume-based purchasing) to paying them for the value they deliver (value-based purchasing), we must acknowledge that we are “commodifying” health-care quality and affordability. By doing so, the economic viability of medical practices and health-care institutions will depend on delivering value, and to the extent that this determines a competitive advantage in the marketplace, providers might be reluctant to share innovations in quality and affordability.
We must not let this happen to health care. Competing on the ability to effectively deploy and manage new innovations to enhance quality and affordability is acceptable. Competing, however, on the access to these innovations is ethically unacceptable for an industry that is indispensable to the health and well-being of its consumers.
Coke and Pepsi do not provide indispensable products to society. It is thus fine for soft-drink makers to keep their recipes top secret and fight vigorously to prevent others from gaining access to their innovations. Health-care providers, however, cannot morally defend refusing to share new products and processes that decrease costs, improve patient experience, decrease morbidity, prolong life, or otherwise enhance quality.
We must, therefore, strive to continuously collaborate with our hospitalist colleagues and HM programs across the country to propagate new innovation. When someone builds a better mouse trap, it should be shared freely so that all patients have the opportunity to benefit. We must not let the pursuit of economic competitive advantage prevent us from collaborating and sharing ideas on how to make our health-care system better.
Conclusion
Fixing health care is complicated, and employing collaboration in order to do so will be required. Hospitalists have vast experience in working effectively with others, and should leverage this experience to lead the charge on efforts to enhance physician-patient collaboration. Hospitalists should strive to continuously collaborate with their colleagues to ensure open access to new discoveries that improve health-care quality and affordability. Those interested in learning more about how to be successful collaborators might find it helpful to seek out additional resources on the subject. Collaboration, by Morten T. Hansen, is a good source on how to turn this concept into action.3
References
- Hoffman A, Emanuel E. Reengineering US health care. JAMA. 2013;309(7):661-662.
- Frost, S. A matter of perspective: deconstructing satisfaction measurements by focusing on patient goals. The Hospitalist. 2013:17(3):59.
- Hansen M. Collaboration: how leaders avoid the traps, create unity, and reap big results. Boston: Harvard Business Press; 2009.
Shaun Frost: Why Hospital Patients' Expectations Should Dictate Their Care
It is difficult to disagree that patients and their families deserve to be satisfied with the care they receive, and furthermore that a satisfying care experience is the foundation upon which the ability to heal is based. Mention the subject of patient satisfaction, however, to care providers, and prepare for many to respond negatively. For most, this frustration likely stems from the challenges associated with satisfaction measurement, and the application of this measurement to provider performance reporting and reimbursement. Perhaps by focusing so intently on quantifying how happy patients are with their care, we have distracted ourselves from the real goal of creating patient experiences that enable optimal healing.
In some respects, healthcare’s preoccupation with satisfaction measurements seems analogous to administering a final examination before teaching the course material. If so, at this juncture, it would be prudent to back up and examine the curriculum required to master the subject matter necessary to perform well on the test. To this end, it is necessary to:
Identify the contributors to a satisfying patient experience, and Focus specifically on understanding patient expectations.
Expectation Examination
An essential reading on the subject of patient experience and satisfaction is a July/August 2005 article in The Hospitalist titled “Patient Satisfaction: the Hospitalist’s Role,” in which Patrick J. Torcson, MD, MMM, FACP, SFHM, introduces “The First Law of Service.”1 According to this law, satisfaction can be mathematically defined as equal to patients’ perceptions of the care they received minus their expectations for that care (satisfaction=perception–expectation). Accordingly, if perception meets or exceeds expectation, an associated degree of satisfaction will be generated.
Both perceptions and expectations can be affected to create satisfaction. Remodeling a hospital lobby is an example of an effort to primarily influence patient perception. When considering efforts to influence patient expectations, it is useful to think of universal versus individual patient requirements, needs, desires, values, and goals. Examples of universal patient expectations (meaning expectations held by all or a majority of patients) would include receiving warm meals at scheduled times, having call lights answered in a timely manner, understanding the side effects of medications, and receiving instructions at the time of discharge. Examples of individual patient expectations (meaning expectations that are personally held by individual patients because of reasons unique to individual circumstances not common to everyone) would be need for low-cost medications due to economic hardship, prioritization of functional improvement versus pain elimination, and tolerance of treatment-related side effects.
It might be fair to say that in its pursuit to create satisfying patient experiences, our healthcare system has focused more on influencing perception and universal patient expectations than it has on addressing unique, personally held patient interests. In the future, we should attend more diligently to individual expectations. By doing so, patients will be better engaged, providers will be better informed, and satisfaction will follow.
Shared Decision-Making
You wouldn’t think of retaining a real estate agent to assist you in purchasing a home without informing that person about your personal needs. In order to satisfy you, the agent must understand what you expect in regard to such issues as price, square footage, yard size, community amenities, school district, proximity to work, etc. Just as your needs in shopping for a home can only be met by considering your personal expectations, your patient’s needs can only be met by understanding their individual healthcare requirements.
Unfortunately, understanding an individual patient’s expectations about their healthcare is more challenging than outlining a list of requirements for their ideal home. Although the reasons for this are multiple (see “Barriers to Understanding Patient Expectations,” left), the solution in large part rests in the application of shared decision-making (SDM).
SDM is defined as a collaborative communication process between provider and patient intended to help the patient decide among multiple acceptable healthcare choices in accordance with their preferences and values. SDM has been demonstrated to positively impact patient satisfaction, as well as care quality, resource utilization, and healthcare costs. A cornerstone feature of SDM is the use of decision aids to assist patients in identifying their personal healthcare expectations while simultaneously educating them about how those expectations apply to care plan options. Decision aids also benefit care providers by creating a standardized framework by which to solicit patients’ input regarding their preferences. When navigated appropriately, SDM balances the clinician’s expertise and knowledge with the patient’s goals and values.
Recent investigations into the application of SDM to HM practice have touted its effectiveness (e.g. when applied to low-risk chest pain evaluations) and questioned the creation of unintended negative consequences (e.g. on hospital resource consumption and affordability).2,3 Despite limited data in the HM setting, several literature reviews examining the effectiveness of SDM across various care sites consistently linked it to greater patient satisfaction.4
It is important to realize that policymakers are lauding the promise of SDM and incorporating its use into rules, regulations, and funding opportunities. For example, the Centers for Medicare & Medicaid Services (CMS) requires SDM to participate in its accountable-care organization (ACO) programs, and several states recently have enacted legislation to promote SDM. Expect thus to experience future pressure to apply SDM in your hospitalist practice. Organizations dedicated to the advancement of SDM include the Society for Participatory Medicine, the Informed Medical Decisions Foundation, the Society for Medical Decision Making, and the Mayo Clinic. More information and resources are available on their websites.
Conclusions
Satisfaction surveys are tools for measuring the quality of patient care experiences. Although satisfaction surveying is an inexact science, and the application of survey results to performance evaluation is challenging, we must remember that the goal is to optimize patient experience. Necessary in the creation of a satisfying patient experience is a robust understanding of patient expectations. SDM is a promising communication strategy that can help both providers and patients better identify the personally held values and goals that determine patient care expectations.
Dr. Frost is president of SHM.
References
- Torcson, P. Patient satisfaction: the hospitalist’s role. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/256805/Patient_Satisfaction_the_Hospitalists_Role.html. Accessed Jan. 30, 2013.
- Hess E, et al. The chest pain choice decision aid. A randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5:251-259.
- Tak, HJ, Meltzer, D. Effect of patient preference in medical decision-making on inpatient care [abstract]. J Hosp Med. 2012;7(Suppl 2):91.
- Hostetter, M, Klein S. Helping patients make better treatment choices with decision aids. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Newsletters/Quality-Matters/2012/October-November/In-Focus.aspx. Accessed Jan. 30, 2013.
It is difficult to disagree that patients and their families deserve to be satisfied with the care they receive, and furthermore that a satisfying care experience is the foundation upon which the ability to heal is based. Mention the subject of patient satisfaction, however, to care providers, and prepare for many to respond negatively. For most, this frustration likely stems from the challenges associated with satisfaction measurement, and the application of this measurement to provider performance reporting and reimbursement. Perhaps by focusing so intently on quantifying how happy patients are with their care, we have distracted ourselves from the real goal of creating patient experiences that enable optimal healing.
In some respects, healthcare’s preoccupation with satisfaction measurements seems analogous to administering a final examination before teaching the course material. If so, at this juncture, it would be prudent to back up and examine the curriculum required to master the subject matter necessary to perform well on the test. To this end, it is necessary to:
Identify the contributors to a satisfying patient experience, and Focus specifically on understanding patient expectations.
Expectation Examination
An essential reading on the subject of patient experience and satisfaction is a July/August 2005 article in The Hospitalist titled “Patient Satisfaction: the Hospitalist’s Role,” in which Patrick J. Torcson, MD, MMM, FACP, SFHM, introduces “The First Law of Service.”1 According to this law, satisfaction can be mathematically defined as equal to patients’ perceptions of the care they received minus their expectations for that care (satisfaction=perception–expectation). Accordingly, if perception meets or exceeds expectation, an associated degree of satisfaction will be generated.
Both perceptions and expectations can be affected to create satisfaction. Remodeling a hospital lobby is an example of an effort to primarily influence patient perception. When considering efforts to influence patient expectations, it is useful to think of universal versus individual patient requirements, needs, desires, values, and goals. Examples of universal patient expectations (meaning expectations held by all or a majority of patients) would include receiving warm meals at scheduled times, having call lights answered in a timely manner, understanding the side effects of medications, and receiving instructions at the time of discharge. Examples of individual patient expectations (meaning expectations that are personally held by individual patients because of reasons unique to individual circumstances not common to everyone) would be need for low-cost medications due to economic hardship, prioritization of functional improvement versus pain elimination, and tolerance of treatment-related side effects.
It might be fair to say that in its pursuit to create satisfying patient experiences, our healthcare system has focused more on influencing perception and universal patient expectations than it has on addressing unique, personally held patient interests. In the future, we should attend more diligently to individual expectations. By doing so, patients will be better engaged, providers will be better informed, and satisfaction will follow.
Shared Decision-Making
You wouldn’t think of retaining a real estate agent to assist you in purchasing a home without informing that person about your personal needs. In order to satisfy you, the agent must understand what you expect in regard to such issues as price, square footage, yard size, community amenities, school district, proximity to work, etc. Just as your needs in shopping for a home can only be met by considering your personal expectations, your patient’s needs can only be met by understanding their individual healthcare requirements.
Unfortunately, understanding an individual patient’s expectations about their healthcare is more challenging than outlining a list of requirements for their ideal home. Although the reasons for this are multiple (see “Barriers to Understanding Patient Expectations,” left), the solution in large part rests in the application of shared decision-making (SDM).
SDM is defined as a collaborative communication process between provider and patient intended to help the patient decide among multiple acceptable healthcare choices in accordance with their preferences and values. SDM has been demonstrated to positively impact patient satisfaction, as well as care quality, resource utilization, and healthcare costs. A cornerstone feature of SDM is the use of decision aids to assist patients in identifying their personal healthcare expectations while simultaneously educating them about how those expectations apply to care plan options. Decision aids also benefit care providers by creating a standardized framework by which to solicit patients’ input regarding their preferences. When navigated appropriately, SDM balances the clinician’s expertise and knowledge with the patient’s goals and values.
Recent investigations into the application of SDM to HM practice have touted its effectiveness (e.g. when applied to low-risk chest pain evaluations) and questioned the creation of unintended negative consequences (e.g. on hospital resource consumption and affordability).2,3 Despite limited data in the HM setting, several literature reviews examining the effectiveness of SDM across various care sites consistently linked it to greater patient satisfaction.4
It is important to realize that policymakers are lauding the promise of SDM and incorporating its use into rules, regulations, and funding opportunities. For example, the Centers for Medicare & Medicaid Services (CMS) requires SDM to participate in its accountable-care organization (ACO) programs, and several states recently have enacted legislation to promote SDM. Expect thus to experience future pressure to apply SDM in your hospitalist practice. Organizations dedicated to the advancement of SDM include the Society for Participatory Medicine, the Informed Medical Decisions Foundation, the Society for Medical Decision Making, and the Mayo Clinic. More information and resources are available on their websites.
Conclusions
Satisfaction surveys are tools for measuring the quality of patient care experiences. Although satisfaction surveying is an inexact science, and the application of survey results to performance evaluation is challenging, we must remember that the goal is to optimize patient experience. Necessary in the creation of a satisfying patient experience is a robust understanding of patient expectations. SDM is a promising communication strategy that can help both providers and patients better identify the personally held values and goals that determine patient care expectations.
Dr. Frost is president of SHM.
References
- Torcson, P. Patient satisfaction: the hospitalist’s role. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/256805/Patient_Satisfaction_the_Hospitalists_Role.html. Accessed Jan. 30, 2013.
- Hess E, et al. The chest pain choice decision aid. A randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5:251-259.
- Tak, HJ, Meltzer, D. Effect of patient preference in medical decision-making on inpatient care [abstract]. J Hosp Med. 2012;7(Suppl 2):91.
- Hostetter, M, Klein S. Helping patients make better treatment choices with decision aids. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Newsletters/Quality-Matters/2012/October-November/In-Focus.aspx. Accessed Jan. 30, 2013.
It is difficult to disagree that patients and their families deserve to be satisfied with the care they receive, and furthermore that a satisfying care experience is the foundation upon which the ability to heal is based. Mention the subject of patient satisfaction, however, to care providers, and prepare for many to respond negatively. For most, this frustration likely stems from the challenges associated with satisfaction measurement, and the application of this measurement to provider performance reporting and reimbursement. Perhaps by focusing so intently on quantifying how happy patients are with their care, we have distracted ourselves from the real goal of creating patient experiences that enable optimal healing.
In some respects, healthcare’s preoccupation with satisfaction measurements seems analogous to administering a final examination before teaching the course material. If so, at this juncture, it would be prudent to back up and examine the curriculum required to master the subject matter necessary to perform well on the test. To this end, it is necessary to:
Identify the contributors to a satisfying patient experience, and Focus specifically on understanding patient expectations.
Expectation Examination
An essential reading on the subject of patient experience and satisfaction is a July/August 2005 article in The Hospitalist titled “Patient Satisfaction: the Hospitalist’s Role,” in which Patrick J. Torcson, MD, MMM, FACP, SFHM, introduces “The First Law of Service.”1 According to this law, satisfaction can be mathematically defined as equal to patients’ perceptions of the care they received minus their expectations for that care (satisfaction=perception–expectation). Accordingly, if perception meets or exceeds expectation, an associated degree of satisfaction will be generated.
Both perceptions and expectations can be affected to create satisfaction. Remodeling a hospital lobby is an example of an effort to primarily influence patient perception. When considering efforts to influence patient expectations, it is useful to think of universal versus individual patient requirements, needs, desires, values, and goals. Examples of universal patient expectations (meaning expectations held by all or a majority of patients) would include receiving warm meals at scheduled times, having call lights answered in a timely manner, understanding the side effects of medications, and receiving instructions at the time of discharge. Examples of individual patient expectations (meaning expectations that are personally held by individual patients because of reasons unique to individual circumstances not common to everyone) would be need for low-cost medications due to economic hardship, prioritization of functional improvement versus pain elimination, and tolerance of treatment-related side effects.
It might be fair to say that in its pursuit to create satisfying patient experiences, our healthcare system has focused more on influencing perception and universal patient expectations than it has on addressing unique, personally held patient interests. In the future, we should attend more diligently to individual expectations. By doing so, patients will be better engaged, providers will be better informed, and satisfaction will follow.
Shared Decision-Making
You wouldn’t think of retaining a real estate agent to assist you in purchasing a home without informing that person about your personal needs. In order to satisfy you, the agent must understand what you expect in regard to such issues as price, square footage, yard size, community amenities, school district, proximity to work, etc. Just as your needs in shopping for a home can only be met by considering your personal expectations, your patient’s needs can only be met by understanding their individual healthcare requirements.
Unfortunately, understanding an individual patient’s expectations about their healthcare is more challenging than outlining a list of requirements for their ideal home. Although the reasons for this are multiple (see “Barriers to Understanding Patient Expectations,” left), the solution in large part rests in the application of shared decision-making (SDM).
SDM is defined as a collaborative communication process between provider and patient intended to help the patient decide among multiple acceptable healthcare choices in accordance with their preferences and values. SDM has been demonstrated to positively impact patient satisfaction, as well as care quality, resource utilization, and healthcare costs. A cornerstone feature of SDM is the use of decision aids to assist patients in identifying their personal healthcare expectations while simultaneously educating them about how those expectations apply to care plan options. Decision aids also benefit care providers by creating a standardized framework by which to solicit patients’ input regarding their preferences. When navigated appropriately, SDM balances the clinician’s expertise and knowledge with the patient’s goals and values.
Recent investigations into the application of SDM to HM practice have touted its effectiveness (e.g. when applied to low-risk chest pain evaluations) and questioned the creation of unintended negative consequences (e.g. on hospital resource consumption and affordability).2,3 Despite limited data in the HM setting, several literature reviews examining the effectiveness of SDM across various care sites consistently linked it to greater patient satisfaction.4
It is important to realize that policymakers are lauding the promise of SDM and incorporating its use into rules, regulations, and funding opportunities. For example, the Centers for Medicare & Medicaid Services (CMS) requires SDM to participate in its accountable-care organization (ACO) programs, and several states recently have enacted legislation to promote SDM. Expect thus to experience future pressure to apply SDM in your hospitalist practice. Organizations dedicated to the advancement of SDM include the Society for Participatory Medicine, the Informed Medical Decisions Foundation, the Society for Medical Decision Making, and the Mayo Clinic. More information and resources are available on their websites.
Conclusions
Satisfaction surveys are tools for measuring the quality of patient care experiences. Although satisfaction surveying is an inexact science, and the application of survey results to performance evaluation is challenging, we must remember that the goal is to optimize patient experience. Necessary in the creation of a satisfying patient experience is a robust understanding of patient expectations. SDM is a promising communication strategy that can help both providers and patients better identify the personally held values and goals that determine patient care expectations.
Dr. Frost is president of SHM.
References
- Torcson, P. Patient satisfaction: the hospitalist’s role. The Hospitalist website. Available at: http://www.the-hospitalist.org/details/article/256805/Patient_Satisfaction_the_Hospitalists_Role.html. Accessed Jan. 30, 2013.
- Hess E, et al. The chest pain choice decision aid. A randomized trial. Circ Cardiovasc Qual Outcomes. 2012;5:251-259.
- Tak, HJ, Meltzer, D. Effect of patient preference in medical decision-making on inpatient care [abstract]. J Hosp Med. 2012;7(Suppl 2):91.
- Hostetter, M, Klein S. Helping patients make better treatment choices with decision aids. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Newsletters/Quality-Matters/2012/October-November/In-Focus.aspx. Accessed Jan. 30, 2013.
Shaun Frost: Call for Transparency in Healthcare Performance Results to Impact Hospitalists
Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.1 The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.
Performance Data Sources
The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.
The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.
Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.
In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.
Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.
Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.
Transparency and Key Stakeholders
The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.
Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.2 Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.
Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).
Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.
Conclusions
Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.
Dr. Frost is president of SHM.
References
- Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
- PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.
Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.1 The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.
Performance Data Sources
The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.
The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.
Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.
In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.
Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.
Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.
Transparency and Key Stakeholders
The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.
Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.2 Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.
Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).
Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.
Conclusions
Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.
Dr. Frost is president of SHM.
References
- Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
- PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.
Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.1 The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.
Performance Data Sources
The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.
The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.
Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.
In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.
Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.
Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.
Transparency and Key Stakeholders
The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.
Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.2 Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.
Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).
Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.
Conclusions
Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.
Dr. Frost is president of SHM.
References
- Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
- PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.
Shaun Frost: Society of Hospital Medicine Supports the Choosing Wisely Campaign (CWC)
SHM is participating in the ABIM Foundation's Choosing Wisely Campaign (CWC).1 Launched earlier this year, the CWC aims to increase awareness about medical practices that may be of little or no benefit to patients. Presently, 26 physician organizations have teamed with the ABIM Foundation to each create a list of “five things physicians and patients should question.” In addition, Consumer Reports (the product ratings organization well known for grading the quality of such items as automobiles and vacuum cleaners) is coordinating the efforts of 11 consumer groups to advance the CWC agenda.
The CWC aims to highlight two pillars of healthcare reform that will receive enhanced attention in the near future: 1. Cost of care, and 2. Patient experience of care. Heretofore healthcare reform efforts have largely been focused on the quality and patient-safety movements. Equally important, however, to policymakers is affordability and care experience. By focusing on tests and procedures of questionable benefit, the CWC aims to directly address costly unnecessary treatment by encouraging care planning that incorporates patient preferences. This is necessary work because research suggests that physician decisions account for 80% of healthcare expenditures, while the tradition of patients entrusting their doctors with complete decision-making authority leads to care that they do not want.2
Choosing Wisely Begins with Medical Professionalism
In 2002, the ABIM Foundation collaborated with the American College of Physicians Foundation and the European Federation of Internal Medicine to jointly author “Medical Professionalism in the New Millennium: A Physician Charter.”3 The charter has since been endorsed by more than 130 organizations and triggered countless improvement initiatives to advance its fundamental principles of patient welfare, patient autonomy, and social justice.
Through project grant support, the ABIM Foundation is emphasizing two key Physician Charter commitments (see Table 1) to advance appropriate healthcare decision-making and encourage stewardship of healthcare resources. The CWC naturally augments this work by focusing on care affordability and decision-making through shared discussions between patients and providers.
SHM’s Involvement
SHM convened a workgroup of hospital medicine quality improvement experts led by John Bulger, DO, the chief quality officer at Geisinger Health System in Pennsylvania. This group solicited from SHM committee members 150 suggested tests and treatments that HM clinicians and their patients should question. After critical analysis, the list was narrowed to exclude suggestions already being advanced by the CWC while focusing on those that represent the largest opportunity for hospitalists to impact on affordability and patient experience.
The list was then submitted to SHM members for comment via survey, resulting in 11 recommended medical interventions that were subjected to comprehensive literature review. Workgroup members then rated these 11 interventions according to the following criteria: validity of supporting evidence, feasibility and degree of hospitalist impact, frequency of occurrence, and cost of occurrence.
Finally, the workgroup collaborated with the SHM board of directors to submit to the ABIM Foundation the ultimate list of “five things hospitalists and their patients should question.” Ricardo Quinonez, MD, at Baylor College of Medicine in Houston, Texas, led a similar process that generated a list of questionable practices in pediatric HM. It, too, was submitted to the ABIM Foundation.
The CWC anticipates publishing SHM’s list in February 2013. In the meantime, please consult the CWC website to find practices commonly performed by hospitalists that have been deemed to be of unclear benefit by other professional medical societies (see “2012 CWC Recommendations for Hospitalists,” left).
SHM plans to build upon this work in the future. Expect to see Choosing Wisely sessions and discussions at the HM13 SHM Annual Meeting in May (www.hospitalmedicine2013.org) focused on creating and teaching QI strategies to implement CWC recommendations. Furthermore, the Center for Hospital Innovation and Improvement will be identifying opportunities to develop mentored implementation QI programs related to Choosing Wisely and its principles.
What You Can Do
Hospitalists can make a huge impact on affordability and patient experience given that most of the country’s healthcare dollar is spent in the hospital, and patients are at their most vulnerable to receiving treatment that they may not want when they are acutely ill. Hospitalists, thus, are uniquely positioned to make a positive impact by embracing the Choosing Wisely Campaign’s principles.
Please commit to assisting SHM by visiting the CWC website and learning about other medical society’s thoughts on “things physicians and patients should question.” Pledge thereafter to engage your patients and their families in healthcare decision-making, especially in situations where the benefits of tests and therapies are unclear.
Attention to care affordability and experience are essential to reforming our broken healthcare system, so let’s lead the charge in these areas and help others who are doing the same.
Dr. Frost is president of SHM.
References
- The ABIM Foundation. Choosing Wisely: An initiative of the ABIM Foundation. Choosing Wisely website. Available at: http://www.choosingwisely.org. Accessed Sept. 25, 2012.
- The ABIM Foundation. Principles Guiding Wise Choices. ABIM Foundation website. Available at: www.abimfoundation.org/Initiatives/~/media/Files/2011-Forum/110411_ABIM%20Stewardship.ashx. Accessed Sept. 25, 2012.
- ABIM Foundation, ACP–ASIM Foundation, European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136(3):243.
SHM is participating in the ABIM Foundation's Choosing Wisely Campaign (CWC).1 Launched earlier this year, the CWC aims to increase awareness about medical practices that may be of little or no benefit to patients. Presently, 26 physician organizations have teamed with the ABIM Foundation to each create a list of “five things physicians and patients should question.” In addition, Consumer Reports (the product ratings organization well known for grading the quality of such items as automobiles and vacuum cleaners) is coordinating the efforts of 11 consumer groups to advance the CWC agenda.
The CWC aims to highlight two pillars of healthcare reform that will receive enhanced attention in the near future: 1. Cost of care, and 2. Patient experience of care. Heretofore healthcare reform efforts have largely been focused on the quality and patient-safety movements. Equally important, however, to policymakers is affordability and care experience. By focusing on tests and procedures of questionable benefit, the CWC aims to directly address costly unnecessary treatment by encouraging care planning that incorporates patient preferences. This is necessary work because research suggests that physician decisions account for 80% of healthcare expenditures, while the tradition of patients entrusting their doctors with complete decision-making authority leads to care that they do not want.2
Choosing Wisely Begins with Medical Professionalism
In 2002, the ABIM Foundation collaborated with the American College of Physicians Foundation and the European Federation of Internal Medicine to jointly author “Medical Professionalism in the New Millennium: A Physician Charter.”3 The charter has since been endorsed by more than 130 organizations and triggered countless improvement initiatives to advance its fundamental principles of patient welfare, patient autonomy, and social justice.
Through project grant support, the ABIM Foundation is emphasizing two key Physician Charter commitments (see Table 1) to advance appropriate healthcare decision-making and encourage stewardship of healthcare resources. The CWC naturally augments this work by focusing on care affordability and decision-making through shared discussions between patients and providers.
SHM’s Involvement
SHM convened a workgroup of hospital medicine quality improvement experts led by John Bulger, DO, the chief quality officer at Geisinger Health System in Pennsylvania. This group solicited from SHM committee members 150 suggested tests and treatments that HM clinicians and their patients should question. After critical analysis, the list was narrowed to exclude suggestions already being advanced by the CWC while focusing on those that represent the largest opportunity for hospitalists to impact on affordability and patient experience.
The list was then submitted to SHM members for comment via survey, resulting in 11 recommended medical interventions that were subjected to comprehensive literature review. Workgroup members then rated these 11 interventions according to the following criteria: validity of supporting evidence, feasibility and degree of hospitalist impact, frequency of occurrence, and cost of occurrence.
Finally, the workgroup collaborated with the SHM board of directors to submit to the ABIM Foundation the ultimate list of “five things hospitalists and their patients should question.” Ricardo Quinonez, MD, at Baylor College of Medicine in Houston, Texas, led a similar process that generated a list of questionable practices in pediatric HM. It, too, was submitted to the ABIM Foundation.
The CWC anticipates publishing SHM’s list in February 2013. In the meantime, please consult the CWC website to find practices commonly performed by hospitalists that have been deemed to be of unclear benefit by other professional medical societies (see “2012 CWC Recommendations for Hospitalists,” left).
SHM plans to build upon this work in the future. Expect to see Choosing Wisely sessions and discussions at the HM13 SHM Annual Meeting in May (www.hospitalmedicine2013.org) focused on creating and teaching QI strategies to implement CWC recommendations. Furthermore, the Center for Hospital Innovation and Improvement will be identifying opportunities to develop mentored implementation QI programs related to Choosing Wisely and its principles.
What You Can Do
Hospitalists can make a huge impact on affordability and patient experience given that most of the country’s healthcare dollar is spent in the hospital, and patients are at their most vulnerable to receiving treatment that they may not want when they are acutely ill. Hospitalists, thus, are uniquely positioned to make a positive impact by embracing the Choosing Wisely Campaign’s principles.
Please commit to assisting SHM by visiting the CWC website and learning about other medical society’s thoughts on “things physicians and patients should question.” Pledge thereafter to engage your patients and their families in healthcare decision-making, especially in situations where the benefits of tests and therapies are unclear.
Attention to care affordability and experience are essential to reforming our broken healthcare system, so let’s lead the charge in these areas and help others who are doing the same.
Dr. Frost is president of SHM.
References
- The ABIM Foundation. Choosing Wisely: An initiative of the ABIM Foundation. Choosing Wisely website. Available at: http://www.choosingwisely.org. Accessed Sept. 25, 2012.
- The ABIM Foundation. Principles Guiding Wise Choices. ABIM Foundation website. Available at: www.abimfoundation.org/Initiatives/~/media/Files/2011-Forum/110411_ABIM%20Stewardship.ashx. Accessed Sept. 25, 2012.
- ABIM Foundation, ACP–ASIM Foundation, European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136(3):243.
SHM is participating in the ABIM Foundation's Choosing Wisely Campaign (CWC).1 Launched earlier this year, the CWC aims to increase awareness about medical practices that may be of little or no benefit to patients. Presently, 26 physician organizations have teamed with the ABIM Foundation to each create a list of “five things physicians and patients should question.” In addition, Consumer Reports (the product ratings organization well known for grading the quality of such items as automobiles and vacuum cleaners) is coordinating the efforts of 11 consumer groups to advance the CWC agenda.
The CWC aims to highlight two pillars of healthcare reform that will receive enhanced attention in the near future: 1. Cost of care, and 2. Patient experience of care. Heretofore healthcare reform efforts have largely been focused on the quality and patient-safety movements. Equally important, however, to policymakers is affordability and care experience. By focusing on tests and procedures of questionable benefit, the CWC aims to directly address costly unnecessary treatment by encouraging care planning that incorporates patient preferences. This is necessary work because research suggests that physician decisions account for 80% of healthcare expenditures, while the tradition of patients entrusting their doctors with complete decision-making authority leads to care that they do not want.2
Choosing Wisely Begins with Medical Professionalism
In 2002, the ABIM Foundation collaborated with the American College of Physicians Foundation and the European Federation of Internal Medicine to jointly author “Medical Professionalism in the New Millennium: A Physician Charter.”3 The charter has since been endorsed by more than 130 organizations and triggered countless improvement initiatives to advance its fundamental principles of patient welfare, patient autonomy, and social justice.
Through project grant support, the ABIM Foundation is emphasizing two key Physician Charter commitments (see Table 1) to advance appropriate healthcare decision-making and encourage stewardship of healthcare resources. The CWC naturally augments this work by focusing on care affordability and decision-making through shared discussions between patients and providers.
SHM’s Involvement
SHM convened a workgroup of hospital medicine quality improvement experts led by John Bulger, DO, the chief quality officer at Geisinger Health System in Pennsylvania. This group solicited from SHM committee members 150 suggested tests and treatments that HM clinicians and their patients should question. After critical analysis, the list was narrowed to exclude suggestions already being advanced by the CWC while focusing on those that represent the largest opportunity for hospitalists to impact on affordability and patient experience.
The list was then submitted to SHM members for comment via survey, resulting in 11 recommended medical interventions that were subjected to comprehensive literature review. Workgroup members then rated these 11 interventions according to the following criteria: validity of supporting evidence, feasibility and degree of hospitalist impact, frequency of occurrence, and cost of occurrence.
Finally, the workgroup collaborated with the SHM board of directors to submit to the ABIM Foundation the ultimate list of “five things hospitalists and their patients should question.” Ricardo Quinonez, MD, at Baylor College of Medicine in Houston, Texas, led a similar process that generated a list of questionable practices in pediatric HM. It, too, was submitted to the ABIM Foundation.
The CWC anticipates publishing SHM’s list in February 2013. In the meantime, please consult the CWC website to find practices commonly performed by hospitalists that have been deemed to be of unclear benefit by other professional medical societies (see “2012 CWC Recommendations for Hospitalists,” left).
SHM plans to build upon this work in the future. Expect to see Choosing Wisely sessions and discussions at the HM13 SHM Annual Meeting in May (www.hospitalmedicine2013.org) focused on creating and teaching QI strategies to implement CWC recommendations. Furthermore, the Center for Hospital Innovation and Improvement will be identifying opportunities to develop mentored implementation QI programs related to Choosing Wisely and its principles.
What You Can Do
Hospitalists can make a huge impact on affordability and patient experience given that most of the country’s healthcare dollar is spent in the hospital, and patients are at their most vulnerable to receiving treatment that they may not want when they are acutely ill. Hospitalists, thus, are uniquely positioned to make a positive impact by embracing the Choosing Wisely Campaign’s principles.
Please commit to assisting SHM by visiting the CWC website and learning about other medical society’s thoughts on “things physicians and patients should question.” Pledge thereafter to engage your patients and their families in healthcare decision-making, especially in situations where the benefits of tests and therapies are unclear.
Attention to care affordability and experience are essential to reforming our broken healthcare system, so let’s lead the charge in these areas and help others who are doing the same.
Dr. Frost is president of SHM.
References
- The ABIM Foundation. Choosing Wisely: An initiative of the ABIM Foundation. Choosing Wisely website. Available at: http://www.choosingwisely.org. Accessed Sept. 25, 2012.
- The ABIM Foundation. Principles Guiding Wise Choices. ABIM Foundation website. Available at: www.abimfoundation.org/Initiatives/~/media/Files/2011-Forum/110411_ABIM%20Stewardship.ashx. Accessed Sept. 25, 2012.
- ABIM Foundation, ACP–ASIM Foundation, European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136(3):243.
Shaun Frost: High-Value Healthcare
In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”1 In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.
The Process
Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”
Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.
There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.
Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”
This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”
Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.
To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.
According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.
The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.
In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.
Conclusion
Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.
Dr. Frost is president of SHM.
Reference
In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”1 In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.
The Process
Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”
Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.
There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.
Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”
This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”
Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.
To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.
According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.
The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.
In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.
Conclusion
Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.
Dr. Frost is president of SHM.
Reference
In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”1 In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.
The Process
Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”
Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.
There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.
Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”
This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”
Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.
To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.
According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.
The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.
In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.
Conclusion
Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.
Dr. Frost is president of SHM.
Reference
How to Be Accountable in Hospital Medicine
In my last column, I outlined the “accountability imperative” facing the specialty of hospital medicine, and I discussed the need to hold ourselves accountable for delivering true, high-value healthcare. However, this is easier said than done; being accountable in the complex environments in which we work is difficult. The key to simplifying accountability rests in deconstructing the concept in a manner that allows us to consistently appeal to its fundamental tenets, so that applying these tenets in our everyday lives is easy. Understanding accountability begins with defining the term.
Accountability Defined
To be truly accountable, one must first appreciate what accountability is, and what it is not. This is beautifully articulated in a well-written book by Connors, Smith, and Hickman titled “The Oz Principle: Getting Results Through Individual and Organizational Accountability.”1 Connors and colleagues advise that we must conceive of accountability as forward-looking versus backward-looking judgment. All too often, society thinks of accountability as a historical or retrospective concept, that accountability is something to invoke when an individual has failed to meet expectations. Defining accountability in this manner casts the concept in a negative light by invoking fear and anxiety; accountability becomes synonymous with punishment, retribution, blame, humiliation, and scrutiny.
“The Oz Principle” suggests that “accountability is more than a confession,” and warns that people who narrowly define accountability in this manner become “obsessed with the past, and blissfully ignorant of the future.” This is sage advice for the profession of medicine. All too often, clinicians and healthcare professionals yearn for a past era in which it was supposedly easier to practice medicine because of independence from rules, regulations, protocols, pathways, performance measurement, and performance reporting. In lamenting the loss of a past era, people risk ignoring the present and thus fail to embrace healthcare reform initiatives that will soon establish new expectations. These new expectations must be met to ensure future success.
It behooves us─hospitalists─to define accountability in a more constructive and future-oriented manner. To this end, Connors and colleagues propose that accountability be conceived of as “a personal choice to rise above one’s circumstances and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by acting proactively to avoid problems, rather than reactively, which forces us to explain why problems occurred. In so doing, we embrace our current situation, actively seek to understand new initiatives compelling us to alter our behavior, recognize the dangers in maintaining outdated status quos, and become actively engaged participants in obligatory change initiatives.
If this is our perspective, genuine, patient-centered care will become the norm, and we will avoid the temptation to dismiss problems as beyond the scope of our responsibility or control. If rising above our circumstances is the motivation, we will not blame poor patient satisfaction survey results on bad hospital food, avoidable hospital readmissions on unavailable post-discharge follow-up appointments, and unnecessary testing on the risk of malpractice litigation.
Furthermore, we must appreciate that our spheres of responsibility overlap those of others in healthcare. As such, success in meeting our expectations directly influences the ability of others to successfully meet theirs, which directly affects our collective ability to achieve healthcare improvement goals. For example, if hospitalists do not effectively communicate patient-care-plan information to nurses, nurses will not be best prepared to respond to patient questions, and patients will potentially be dissatisfied with their hospital experience. In such circumstances, it would be unfair for the hospitalist to blame poor patient satisfaction scores on nursing, because patient dissatisfaction could have been avoided had the hospitalist been accountable for sufficient communication of care-planning information.
Examples such as this turn the spotlight on healthcare professionals. We are jointly accountable for the delivery of high-value healthcare, and are interdependent on each other in this regard. According to “The Oz Principle,” “when people view their accountability for results as something larger than doing their own jobs, they find themselves feeling accountable for things beyond what a literal interpretation of their job description may suggest.”
Don’t Be a Victim
The key to maintaining a future-oriented and proactive view of accountability (pushing us to consistently rise above our circumstances) is to not fall trap to becoming a victim. Connors and colleagues caution that when confronted with poor results and suboptimal performance, there is a natural temptation to make excuses, point fingers at others, create arguments for why we are not to blame, and otherwise rationalize why we are not accountable. Unfortunately, this attitude only perpetuates the myopically negative view of accountability “as a confession,” to be invoked to scrutinize, blame, or punish. A victimization mentality leads to the creation of cultures in which “saving face” is more important than solving problems, and, according to “The Oz Principle,” “quick fixes are favored over long-term solutions, immediate gains are favored over enduring progress, and process is favored over results.”
The danger of favoring process over results seems particularly germane to healthcare quality improvement (QI). In the complex, fast-moving, and pressurized environment of the hospital, it is easy to become satisfied with creating and deploying processes to address such issues as glycemic control, VTE prevention, or safe transitions of care. These processes are surely necessary, but they are certainly not sufficient.
Results are what we are aiming to achieve—not processes. In order to achieve results, the process must be actively managed, and the participants engaged in the processes must hold themselves─and each other─accountable for achieving the results that the processes are designed to effect.
Connors and colleagues write that “accountability for results rests at the very core of continuous improvement....The essence of these programs boils down to getting people to rise above their circumstances to do whatever it takes to get the results they want.” In order for HM to rise above current healthcare circumstances, we must never play the victim role. Blaming others will only keep us mired in current dysfunctional situations, preventing us from breaking free of untenable status quos that prohibit the delivery of high-quality and cost-effective patient care.
Conclusion
Accountability is difficult, especially for hospitalists. The time, though, is now for each of us to embrace accountability, because we will be expected to perform at increasingly higher levels of sophistication in the future. The first step to embracing accountability is to understand the concept, and in my next column, I will further describe concepts that demystify accountability by making it easier to apply in our everyday experiences.
Dr. Frost is president of SHM.
Reference
In my last column, I outlined the “accountability imperative” facing the specialty of hospital medicine, and I discussed the need to hold ourselves accountable for delivering true, high-value healthcare. However, this is easier said than done; being accountable in the complex environments in which we work is difficult. The key to simplifying accountability rests in deconstructing the concept in a manner that allows us to consistently appeal to its fundamental tenets, so that applying these tenets in our everyday lives is easy. Understanding accountability begins with defining the term.
Accountability Defined
To be truly accountable, one must first appreciate what accountability is, and what it is not. This is beautifully articulated in a well-written book by Connors, Smith, and Hickman titled “The Oz Principle: Getting Results Through Individual and Organizational Accountability.”1 Connors and colleagues advise that we must conceive of accountability as forward-looking versus backward-looking judgment. All too often, society thinks of accountability as a historical or retrospective concept, that accountability is something to invoke when an individual has failed to meet expectations. Defining accountability in this manner casts the concept in a negative light by invoking fear and anxiety; accountability becomes synonymous with punishment, retribution, blame, humiliation, and scrutiny.
“The Oz Principle” suggests that “accountability is more than a confession,” and warns that people who narrowly define accountability in this manner become “obsessed with the past, and blissfully ignorant of the future.” This is sage advice for the profession of medicine. All too often, clinicians and healthcare professionals yearn for a past era in which it was supposedly easier to practice medicine because of independence from rules, regulations, protocols, pathways, performance measurement, and performance reporting. In lamenting the loss of a past era, people risk ignoring the present and thus fail to embrace healthcare reform initiatives that will soon establish new expectations. These new expectations must be met to ensure future success.
It behooves us─hospitalists─to define accountability in a more constructive and future-oriented manner. To this end, Connors and colleagues propose that accountability be conceived of as “a personal choice to rise above one’s circumstances and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by acting proactively to avoid problems, rather than reactively, which forces us to explain why problems occurred. In so doing, we embrace our current situation, actively seek to understand new initiatives compelling us to alter our behavior, recognize the dangers in maintaining outdated status quos, and become actively engaged participants in obligatory change initiatives.
If this is our perspective, genuine, patient-centered care will become the norm, and we will avoid the temptation to dismiss problems as beyond the scope of our responsibility or control. If rising above our circumstances is the motivation, we will not blame poor patient satisfaction survey results on bad hospital food, avoidable hospital readmissions on unavailable post-discharge follow-up appointments, and unnecessary testing on the risk of malpractice litigation.
Furthermore, we must appreciate that our spheres of responsibility overlap those of others in healthcare. As such, success in meeting our expectations directly influences the ability of others to successfully meet theirs, which directly affects our collective ability to achieve healthcare improvement goals. For example, if hospitalists do not effectively communicate patient-care-plan information to nurses, nurses will not be best prepared to respond to patient questions, and patients will potentially be dissatisfied with their hospital experience. In such circumstances, it would be unfair for the hospitalist to blame poor patient satisfaction scores on nursing, because patient dissatisfaction could have been avoided had the hospitalist been accountable for sufficient communication of care-planning information.
Examples such as this turn the spotlight on healthcare professionals. We are jointly accountable for the delivery of high-value healthcare, and are interdependent on each other in this regard. According to “The Oz Principle,” “when people view their accountability for results as something larger than doing their own jobs, they find themselves feeling accountable for things beyond what a literal interpretation of their job description may suggest.”
Don’t Be a Victim
The key to maintaining a future-oriented and proactive view of accountability (pushing us to consistently rise above our circumstances) is to not fall trap to becoming a victim. Connors and colleagues caution that when confronted with poor results and suboptimal performance, there is a natural temptation to make excuses, point fingers at others, create arguments for why we are not to blame, and otherwise rationalize why we are not accountable. Unfortunately, this attitude only perpetuates the myopically negative view of accountability “as a confession,” to be invoked to scrutinize, blame, or punish. A victimization mentality leads to the creation of cultures in which “saving face” is more important than solving problems, and, according to “The Oz Principle,” “quick fixes are favored over long-term solutions, immediate gains are favored over enduring progress, and process is favored over results.”
The danger of favoring process over results seems particularly germane to healthcare quality improvement (QI). In the complex, fast-moving, and pressurized environment of the hospital, it is easy to become satisfied with creating and deploying processes to address such issues as glycemic control, VTE prevention, or safe transitions of care. These processes are surely necessary, but they are certainly not sufficient.
Results are what we are aiming to achieve—not processes. In order to achieve results, the process must be actively managed, and the participants engaged in the processes must hold themselves─and each other─accountable for achieving the results that the processes are designed to effect.
Connors and colleagues write that “accountability for results rests at the very core of continuous improvement....The essence of these programs boils down to getting people to rise above their circumstances to do whatever it takes to get the results they want.” In order for HM to rise above current healthcare circumstances, we must never play the victim role. Blaming others will only keep us mired in current dysfunctional situations, preventing us from breaking free of untenable status quos that prohibit the delivery of high-quality and cost-effective patient care.
Conclusion
Accountability is difficult, especially for hospitalists. The time, though, is now for each of us to embrace accountability, because we will be expected to perform at increasingly higher levels of sophistication in the future. The first step to embracing accountability is to understand the concept, and in my next column, I will further describe concepts that demystify accountability by making it easier to apply in our everyday experiences.
Dr. Frost is president of SHM.
Reference
In my last column, I outlined the “accountability imperative” facing the specialty of hospital medicine, and I discussed the need to hold ourselves accountable for delivering true, high-value healthcare. However, this is easier said than done; being accountable in the complex environments in which we work is difficult. The key to simplifying accountability rests in deconstructing the concept in a manner that allows us to consistently appeal to its fundamental tenets, so that applying these tenets in our everyday lives is easy. Understanding accountability begins with defining the term.
Accountability Defined
To be truly accountable, one must first appreciate what accountability is, and what it is not. This is beautifully articulated in a well-written book by Connors, Smith, and Hickman titled “The Oz Principle: Getting Results Through Individual and Organizational Accountability.”1 Connors and colleagues advise that we must conceive of accountability as forward-looking versus backward-looking judgment. All too often, society thinks of accountability as a historical or retrospective concept, that accountability is something to invoke when an individual has failed to meet expectations. Defining accountability in this manner casts the concept in a negative light by invoking fear and anxiety; accountability becomes synonymous with punishment, retribution, blame, humiliation, and scrutiny.
“The Oz Principle” suggests that “accountability is more than a confession,” and warns that people who narrowly define accountability in this manner become “obsessed with the past, and blissfully ignorant of the future.” This is sage advice for the profession of medicine. All too often, clinicians and healthcare professionals yearn for a past era in which it was supposedly easier to practice medicine because of independence from rules, regulations, protocols, pathways, performance measurement, and performance reporting. In lamenting the loss of a past era, people risk ignoring the present and thus fail to embrace healthcare reform initiatives that will soon establish new expectations. These new expectations must be met to ensure future success.
It behooves us─hospitalists─to define accountability in a more constructive and future-oriented manner. To this end, Connors and colleagues propose that accountability be conceived of as “a personal choice to rise above one’s circumstances and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by acting proactively to avoid problems, rather than reactively, which forces us to explain why problems occurred. In so doing, we embrace our current situation, actively seek to understand new initiatives compelling us to alter our behavior, recognize the dangers in maintaining outdated status quos, and become actively engaged participants in obligatory change initiatives.
If this is our perspective, genuine, patient-centered care will become the norm, and we will avoid the temptation to dismiss problems as beyond the scope of our responsibility or control. If rising above our circumstances is the motivation, we will not blame poor patient satisfaction survey results on bad hospital food, avoidable hospital readmissions on unavailable post-discharge follow-up appointments, and unnecessary testing on the risk of malpractice litigation.
Furthermore, we must appreciate that our spheres of responsibility overlap those of others in healthcare. As such, success in meeting our expectations directly influences the ability of others to successfully meet theirs, which directly affects our collective ability to achieve healthcare improvement goals. For example, if hospitalists do not effectively communicate patient-care-plan information to nurses, nurses will not be best prepared to respond to patient questions, and patients will potentially be dissatisfied with their hospital experience. In such circumstances, it would be unfair for the hospitalist to blame poor patient satisfaction scores on nursing, because patient dissatisfaction could have been avoided had the hospitalist been accountable for sufficient communication of care-planning information.
Examples such as this turn the spotlight on healthcare professionals. We are jointly accountable for the delivery of high-value healthcare, and are interdependent on each other in this regard. According to “The Oz Principle,” “when people view their accountability for results as something larger than doing their own jobs, they find themselves feeling accountable for things beyond what a literal interpretation of their job description may suggest.”
Don’t Be a Victim
The key to maintaining a future-oriented and proactive view of accountability (pushing us to consistently rise above our circumstances) is to not fall trap to becoming a victim. Connors and colleagues caution that when confronted with poor results and suboptimal performance, there is a natural temptation to make excuses, point fingers at others, create arguments for why we are not to blame, and otherwise rationalize why we are not accountable. Unfortunately, this attitude only perpetuates the myopically negative view of accountability “as a confession,” to be invoked to scrutinize, blame, or punish. A victimization mentality leads to the creation of cultures in which “saving face” is more important than solving problems, and, according to “The Oz Principle,” “quick fixes are favored over long-term solutions, immediate gains are favored over enduring progress, and process is favored over results.”
The danger of favoring process over results seems particularly germane to healthcare quality improvement (QI). In the complex, fast-moving, and pressurized environment of the hospital, it is easy to become satisfied with creating and deploying processes to address such issues as glycemic control, VTE prevention, or safe transitions of care. These processes are surely necessary, but they are certainly not sufficient.
Results are what we are aiming to achieve—not processes. In order to achieve results, the process must be actively managed, and the participants engaged in the processes must hold themselves─and each other─accountable for achieving the results that the processes are designed to effect.
Connors and colleagues write that “accountability for results rests at the very core of continuous improvement....The essence of these programs boils down to getting people to rise above their circumstances to do whatever it takes to get the results they want.” In order for HM to rise above current healthcare circumstances, we must never play the victim role. Blaming others will only keep us mired in current dysfunctional situations, preventing us from breaking free of untenable status quos that prohibit the delivery of high-quality and cost-effective patient care.
Conclusion
Accountability is difficult, especially for hospitalists. The time, though, is now for each of us to embrace accountability, because we will be expected to perform at increasingly higher levels of sophistication in the future. The first step to embracing accountability is to understand the concept, and in my next column, I will further describe concepts that demystify accountability by making it easier to apply in our everyday experiences.
Dr. Frost is president of SHM.
Reference
Shaun Frost: Accountability Is Key to Hospital Medicine's Success
As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).
We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.
Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.
The Accountability Imperative
If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”
Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.1 The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.
The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.
Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1
Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.
Accountability and Autonomy
Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.
Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.2 He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”
Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.
Failure to Perform Not an Option
It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.
Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”
Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.
Dr. Frost is president of SHM.
References
As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).
We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.
Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.
The Accountability Imperative
If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”
Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.1 The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.
The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.
Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1
Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.
Accountability and Autonomy
Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.
Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.2 He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”
Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.
Failure to Perform Not an Option
It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.
Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”
Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.
Dr. Frost is president of SHM.
References
As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).
We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.
Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.
The Accountability Imperative
If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”
Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.1 The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.
The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.
Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1
Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.
Accountability and Autonomy
Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.
Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.2 He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”
Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.
Failure to Perform Not an Option
It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.
Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”
Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.
Dr. Frost is president of SHM.
References