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Title: Medical Staff, Board and Hospital: Where the Rubber Hits th


1
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

2
  • Alice G. Gosfield, JD
  • Alice G. Gosfield and Associates, PC
  • 2309 Delancey PlacePhiladelphia PA 19103(215)
    735-2384
  • Agosfield_at_gosfield.com
  • www.gosfield.com
  • James L. Reinertsen, MD
  • The Reinertsen Group
  • 375 East Aspen Meadow Lane
  • Alta, WY 83414
  • (307) 353-2294
  • reinertsen_at_att.net
  • www.reinertsengroup.com

3
  • Every system is perfectly designed to achieve
    the results it gets.
  • Donald Berwick, M.D.

4
  • The American health care system is perfectly
    designed to produce dazzling technologies, large
    numbers of exceptionally well-trained doctors,
    very high costs, serious safety risks, underuse,
    overuse, and misuse of resources, mind-boggling
    administrative waste, lack of access for a
    significant number of Americans, and distrust and
    dissatisfaction for virtually everyoneincluding
    the key professionals who are needed to deliver
    quality care.

5
  • Perhaps the most troublesome piece of data from
    the past 3 years
  • More than 40 of nurses surveyed would not feel
    comfortable having a family member or loved one
    cared for in the facility where they worked.
  • American Nurses Association, 2001

6
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7
Every system is perfectly designed to produce
the results it gets.Berwick
8
Hospital Mortality Rates vs Standardised
ReimbursementTop 10 and bottom 10 HSMR hospitals
USA
9
SummaryThe Medical Staff Organization is part
of the hospital system that is producing these
results. If we want different results, its
likely that the Medical Staff will need to change
how it works, and what it does.
10
The Hospital Quality Mandate
  • Crossing the Quality Chasm
  • Leapfrog
  • Commercial Report Cards
  • Government Report Cards
  • Data to Consumers Healthgrades.com,
    DoctorQuality.com, US News and World Report,
    Hospital Mortality Rates

11
Tensions Among the Players
  • Invasion of the body parts snatchers
  • Defensive economic credentialing
  • I dont see those kinds of people
  • Hes got heads for the beds and knives for hire
  • Its not my job to worry about this
  • We are about market share and bottom line

12
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

13
External Mandates
  • Medicare Conditions of Participation
  • JCAHO deemed status
  • State licensure rules
  • HCQIA

14
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

15
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
  • Dont hurt me mortality rate, ADEs, mishaps

16
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

17
If Physicians Cant Do This, Who Can?
  • Plenary licensure
  • Portal to the rest of the system
  • The essence of physician-patient relationship
    explain, predict and change
  • The need for time and touch as a quality concern

18
Future Medical Staff Role Driving Quality
Then a miracle happens?
Current Medical Staff Role Marginalized
19
Future Medical Staff Role Driving Quality
  • Take a leadership stance
  • Learn and use quality methods
  • Practice the science of medicine as a team

Current Medical Staff Role Marginalized
20
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

21
Principles for physician leadership (2)
  • Pay attention to process, not structure
  • Do something real and meaningful take a risk
  • Dont let one loud negative voice stop you
  • Work across boundaries you need administrators,
    and they need you
  • Start by defining reality, using data, on a small
    scale, about something important

22
Levels of physician leadership in transforming
the Medical Staff
  • Lead yourself
  • Lead your organization
  • Lead your profession

23
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

24
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
25
Lead yourself Learn Quality Methods
  • Read The Improvement Guide, Langley et al.,
    Jossey Bass, 1996
  • Enroll in Intermountain Health Cares ATP Program
  • Go to the IHI Annual Forum, December 2-5, 2003,
    New Orleans
  • Start a rapid cycle of improvement in something
    important in your own practice e.g. touch time

26
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

27
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28
The 2x2 Planning Matrix
ICU Admission
Yes
No
Yes
Comfort Care Only
No
29
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?

30
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

31
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

32
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 cant expect different results without a
    change in some aspects of physician culture

33
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?

34
  • We are losing our clinical autonomy in part
    because the public has learned that the basis for
    it, the full power of our scientific knowledge,
    is not being consistently applied for their
    benefit.

35
  • PHYSICIAN CULTURE
  • We regularly engage in vigorous conversations
    about clinical evidence with our colleagues.
  • But we seldom enter into those conversations with
    the clear understanding that any conclusions we
    reach will be translated into a system of
    standing orders, reminders, measurements,
    feedback loops, and other steps to implement any
    consensus that emerges from the dialogue.

36
A paradox more individual autonomy means less
professional autonomy
  • We talk about evidence in groups
  • We implement it as individuals
  • The resulting variation looks like the Tower of
    Babel, to our nurses and pharmacists.
  • Our results fall short of what we and our
    patients want
  • Society acts to reduce our professional autonomy

37
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 doesnt order
    them?
  • If you reached agreement on a list of these
    operating systems, how would you make sure that
    they are done, reliably?
  • How would incorporate new evidence into these
    operating systems?

38
Does practicing clinical science as a team make a
difference for patients?
39
Practicing science as a team CABG mortality at
BIDMC
40
Does practicing clinical science as a team make
life better for physicians?
41
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.

42
Hospital Boards Role in Quality Setting Aims,
Building Will
  • Understand the important things the community
    expects from your hospital.
  • See that a few system-level measures of those
    things are established, understood, and monitored
    (the Big Dots.)
  • Aim to improve the Big Dots, and link the
    improvement of those things to your main
    strategic goals.
  • Build the hospitals will to achieve these aims.
  • Maintain constancy of purpose for the long-term
    quality transformation of the hospital.
  • Promote collaboration across the community for
    redesign of care.

43
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

44
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 cant expect better results without changing
    the system, including the Medical Staff
  • Medical Staff organizations cant do this alone
    cooperation with Boards and Administrators will
    be essential to success.
  • This would be goodreally goodfor the medical
    profession, but most importantly, for our
    patients.

45
Resources
  • Reinertsen, Zen and the Art of Autonomy
    Maintenance, Annals of Internal Medicine, June
    17, 2003 (in press)
  • Gosfield, Whither Medical Staffs? Rethinking
    the Role of the Staff in the New Quality Era,
    HEALTH LAW HANDBOOK, (A. Gosfield, ed., 2003)
    pp.141-217, available at www.gosfield.com/publicat
    ions)

46
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-assn.org/ama1/pub/upload/mm/21/qual
    ity_culture.pdf
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