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Medical Staff, Board and Hospital: Where the Rubber Hits the Road in the Quest for Quality Alice G. Gosfield, JD James L Reinertsen, MD June 14, 2003

Alice G. Gosfield, JD

Alice G. Gosfield and Associates, PC 2309 Delancey Place Philadelphia PA 19103 (215) 735-2384 [email protected]

James L. Reinertsen, MD

The Reinertsen Group 375 East Aspen Meadow Lane Alta, WY 83414 (307) 353-2294 [email protected]

“Every system is perfectly designed to achieve the results it gets.” Donald Berwick, M.D.

The American health care system is perfectly designed to produce dazzling technologies, large numbers of exceptionally well-trained doctors, very high costs, serious safety risks, underuse, overuse, and misuse of resources, mind boggling administrative waste, lack of access for a significant number of Americans, and distrust and dissatisfaction for virtually everyone —

including the key professionals who are needed to deliver quality care.

Perhaps the most troublesome piece of data from the past 3 years…

More than 40% of nurses surveyed would not feel comfortable having a family member or loved one cared for in the facility where they worked


American Nurses Association, 2001

“Every system is perfectly designed to produce the results it gets.”


200 180 160 140 120 100 80 60 40 20 0 $0

Hospital Mortality Rates vs Standardised Reimbursement Top 10 and bottom 10 HSMR hospitals USA

$5,000 $10,000 $15,000

Summary: The Medical Staff Organization is part of the hospital “system” that is producing these results. If we want different results, it’s likely that the Medical Staff will need to change how it works, and what it does.

The Hospital Quality Mandate Crossing the Quality Chasm Leapfrog Commercial Report Cards Government Report Cards Data to Consumers:,, US News and World Report, Hospital Mortality Rates…

Tensions Among the Players Invasion of the body parts snatchers Defensive economic credentialing “I don’t see those kinds of people” “He’s got heads for the beds and knives for hire” “It’s not my job to worry about this” “We are about market share and bottom line”

How the Medical Staff Plays Today Self-governed, autonomized and excluded from real power Individualized credentialing Barely true review for privileges: only for serial maimers Avoidance of NPDB reports: “there but for the grace of God go I” Difficult to get a quorum at Medical Staff meetings

External Mandates Medicare Conditions of Participation JCAHO: “deemed status” State licensure rules HCQIA

What absorbs the Medical Staff today?

Economic credentialing EMTALA on call obligations Using NPPs Cross departmental privileges (i.e., clinical turf) Board, Administration, and Medical Staff communication failures

Questions Are these the highest and best uses of the Medical Staff?

Do any of these activities have a meaningful impact on the most important things patients expect when they come into a hospital?

– Cure me: outcomes – Heal me: patient satisfaction – Don’t hurt me: mortality rate, ADE’s, mishaps

A Better Role for the Medical Staff Become the primary driver of quality of care in the hospital, and the community Take aim at major issues such as mortality rates, patient safety, nurse staffing, and professional quality of life Accept accountability as a medical staff for the results of the hospital as a care system

If Physicians Can’t Do This, Who Can?

Plenary licensure Portal to the rest of the system The essence of physician-patient relationship: explain, predict and change The need for time and touch as a quality concern

Current Medical Staff Role: Marginalized Then a miracle happens…?

Future Medical Staff Role: Driving Quality

Current Medical Staff Role: Marginalized •

Take a leadership stance

Learn and use quality methods

Practice the science of medicine as a team

Future Medical Staff Role: Driving Quality

Principles for physician leadership Involve physicians at the earliest stages of initiatives that will affect them Identify the real leaders: not always the one with the crown and scepter Build trust: Do what you say, say what you do consistently over time Communicate openly, frequently, candidly Be willing to be held accountable for participation

Principles for physician leadership (2) Pay attention to process, not structure Do something real and meaningful: take a risk Don’t let one loud negative voice stop you Work across boundaries: you need administrators, and they need you Start by defining reality, using data, on a small scale, about something important

Levels of physician leadership in transforming the Medical Staff

Lead yourself Lead your organization Lead your profession

Lead Yourself: Get in Motion Read “Crossing the Quality Chasm” Talk to your patients and employers about how they see your practice Personally interview some nurses and doctors involved in a recent, serious harmful event Commit: voluntary, public, permanent

This is the true joy in life, to be used for a purpose you consider a mighty one, to be a force of nature, rather than a feverish, selfish clod of ailments and grievances complaining that the world will not devote itself to making you happy.

G.B. Shaw

Lead yourself: Learn Quality Methods Read

The Improvement Guide,

Langley et al., Jossey Bass, 1996 Enroll in Intermountain Health Care’s ATP Program Go to the IHI Annual Forum, December 2-5, 2003, New Orleans Start a rapid cycle of improvement in something important in your own practice e.g. touch time

Lead Your Organization Gather some data about performance on something important e.g. review the last 50 consecutive deaths at your hospital Ask the Board to adopt a serious goal for improvement of mortality rates Work with Administration to take action on what you learn about patterns of deaths in your hospital – Teamwork, Nurse Staffing, Coordination of Care, Adverse Events, ICU organization…

Looking Under the Hood: 50 Consecutive Deaths in 27 hospitals Comfort Care Non Comfort Care ICU Admission 40/1350 3.0% (0-14%) 548/1350 40.6% (16-64%) No ICU Admission 179/1350 13.3% (0-40%) 583/1350 43.2% (18-64%)

The 2x2 Planning Matrix Comfort Care Only Yes No ICU Admission Yes Develop and execute a “policy” limiting use of ICU for comfort care only No Develop alternatives to hospitalization Use best practices in End of Life care Increase capability for comfort care on the patient care units Responsiveness to nurse ICU redesign: closed units, bundles, daily goals sheet, multidisciplinary rounds… Better communication and planning Pre-code team, hospitalists Reduction of adverse events

Reducing mortality: what the Medical Staff could do Standardize, simplify common hazardous processes – PCA drips: from 40 solutions to 4, from 4 devices to 1 – Narcotics: automatic substitution for Demerol orders – Standing order sets: “start heparin” Credential teams based on evidence: – ICUs: who should be taking care of critically ill patients?

More on mortality: what the medical staff might do Implement “operating systems” – Ventilator bundle: 5 actions for every ventilated patient, reduce mortality up to 30% – Wound infection bundle: 6 actions for every operated patient, reduce infections up to 60% Promote a culture of responsiveness to nurses’ concerns, teamwork, communication

Where will you find the time for these Medical Staff activities?

Contract out pieces of corrective action including fair hearings Use the Stark regulation to get help from the hospital (make compliance clinically relevant)

Standardize and simplify your clinical work

Lead Your Profession Medical Staff organizations have viewed the practice of medicine as an individual endeavor, rather than a team activity This professional viewpoint is part of the “system that is perfectly designed to produce the results it gets.” You can’t expect different results without a change in some aspects of physician culture

Why have physicians lost autonomy?

Failure of the many to clean up the messes of the few Fading political power, as more physicians put self-interest above patient interest Not practicing the art of medicine

Not practicing the science?

We are losing our clinical autonomy in part because the public has learned that the basis for it, the full power of our scientific knowledge, is not being consistently applied for their benefit.


We regularly engage in vigorous conversations about clinical evidence with our colleagues.

But we seldom enter into those conversations with the clear understanding that any conclusions we reach will be translated into a system of standing orders, reminders, measurements, feedback loops, and other steps to implement any consensus that emerges from the dialogue.

A paradox: more


autonomy means less


autonomy We talk about evidence in groups We implement it as individuals The resulting variation looks like the Tower of Babel, to our nurses and pharmacists.

Our results fall short of what we and our patients want Society acts to reduce our professional autonomy

Questions for your Medical Staff Beyond sterile technique in the OR, could you agree on evidence-based practices that should be done for a particular diagnosis or procedure for every patient, even if a doctor doesn’t order them?

If you reached agreement on a list of these “operating systems,” how would you make sure that they are done, reliably?

How would incorporate new evidence into these operating systems?

Does practicing clinical science as a team make a difference for patients?

Practicing science as a team: CABG mortality at BIDMC

9 8 7 2 1 0 4 3 6 5 O ct D ec F eb A pr 16 Evidence-based Processes Standardized Jan-Apr 01 Ju n A ug O ct D ec Oct 99-Oct 01 F eb A pr Ju n A ug O ct

Does practicing clinical science as a team make life better for physicians?

A working hypothesis for physician leaders

If we practice the science of medicine as teams, society might give us the privilege of practicing the art of medicine as individuals. By sharing individual autonomy in the science, we can regain professional autonomy, and rediscover precious touch time.

Hospital Board’s Role in Quality: Setting Aims, Building Will Understand the important things the community expects from your hospital.

See that a few system-level measures of those things are established, understood, and monitored (the “Big Dots.”) Aim to improve the Big Dots, and link the improvement of those things to your main strategic goals.

Build the hospital’s will to achieve these aims.

Maintain constancy of purpose for the long-term quality transformation of the hospital.

Promote collaboration across the community for redesign of care.

MD and Administrator Roles in Quality: Generating Ideas, Executing Change e.g.

Establish safe levels of nurse staffing, and give nurses a large measure of control of their practice environment.

Establish an environment that fosters professional teamwork between doctors and nurses.

Manage hospital flow so that the right patients are put on the right units at the right time.

Apply the known evidence to care: team rounds, ventilator bundles, order sets… Use Improvement Science in daily work

Summary Hospitals are under enormous pressure to produce better results The Medical Staff organization is a part of the “system” producing the current results We can’t expect better results without changing the system, including the Medical Staff Medical Staff organizations can’t do this alone: cooperation with Boards and Administrators will be essential to success.

This would be good patients.

—really good—for the medical profession, but most importantly, for our

Resources Reinertsen, “Zen and the Art of Autonomy Maintenance”,

Annals of Internal Medicine

, June 17, 2003 (in press) Gosfield, “Whither Medical Staffs?: Rethinking the Role of the Staff in the New Quality Era”,


, (A. Gosfield, ed., 2003) pp.141-217, available at )

More Resources Reinertsen, Boards, Administrators, Medical Staffs and Quality: Sorting Out the Roles

Trustee, (

September, 2003, in press) Gosfield, “Quality and Clinical Culture: The Critical Role of Physicians in Accountable Health Care Organizations,” AMA, 1998, http://www.ama e.pdf