David L. Potash, MD, MBA, Senior Vice President, Medical Director, Press Ganey Associates
Several current trends – value-based purchasing, transparency and increasing costs – make clinical performance management more and more important for hospital managers. Without being able to track inpatient clinical outcomes, cost-efficiency of treatment, regulatory and compliance measures and patient experience of care, a hospital will face serious hurdles to success in today’s climate.
In the past, hospital managers concentrated on processes that they could control: staffing, supply costs and so on. Today, however, clinical management requires the active involvement of medical staff physicians, whose decisions drive most of the costs and outcomes associated with patient admissions. More than ever, it is necessary for hospital management to share performance data with physicians, to work with them to identify improvement opportunities and to change behaviors and processes.
Our clinical management product, Clinical PerformerSM
, is designed specifically for these challenges. Many of us have faced physician skepticism and rejection of patient experience survey results. When you also add in cost of care numbers, quality outcomes numbers and quality process numbers, this initial reaction by many physicians takes on increased concern. Much of the value of Clinical Performer is its ability to report by physician (and physician group) on actual results and to show benchmark results that show either normative or best practice results.
So what happens when a physician is suddenly presented by the chief medical officer with a report consisting of lots of numbers, with the physician’s name in large print at the top? Physicians who learned to use these data while training or at another hospital will want to know the data sources and methodologies that create the reports. However, physicians who have never seen this type of report will almost always challenge it in predictable ways:
- The “so what?” response: “What am I supposed to do with this?”
- The “it’s not my problem” response: “I just practice medicine here to the best of my ability. It’s up to hospital management to take care of the business aspect and keep the doors open.”
- The “my patients really are sicker” response: “You can’t compare me to these benchmarks because my patients are not routine.”
- The “uh-oh, am I in trouble?” response: “How will these numbers be used to punish me?”
- The “cookbook medicine” response: “Are you planning to require all physicians to follow pre-set treatment protocols, instead of treating each patient as an individual?”
- The “numbers are wrong” response: “This says that I had 46 patients in June, and I know for a fact that I had 45. If that is wrong, all the other numbers can’t be trusted.”
At first blush, it looks as if the physicians are trying to distance themselves from the reports. Many hospital managers have asked me why physicians are so non-receptive initially. Actually, it is easy to understand their reaction based on some known physician sensitivities:
- The idea of collecting data, and making diagnoses, is at the scientific heart of the practice of medicine. If data can be shown to be valuable, physicians will use it.
- Physicians are skeptical that administrative data will be used appropriately and that inappropriate assumptions will be drawn about efficiency and quality.
- Physicians have seen these data misused, particularly by managed care companies who use physician profiling to steer patients to lower-cost physicians.
- Physicians are trained to be very critical of scientific studies, and to look through results and methodologies to determine if the numbers really support the findings that the researchers claim. Whenever they are confronted with a page of numbers, they often unconsciously put on their “peer reviewer” hat.
- Professional autonomy is a deeply valued concept by physicians. Being told what to do doesn’t work, as opposed to being presented with evidence-based information.
- Attribution of a patient to a physician for reporting purposes can be difficult and misleading. For example, a physician may be identified as the attending physician for a case, when most of the orders came from associated consultants.
- Most (arguably, all) physicians try to do their best for each patient. Suddenly being confronted by various “scores”, particularly when lower than associated benchmarks, is threatening. This is particularly so when the physician didn’t know anyone was keeping score, and doesn’t understand the scoring “rules.”
All of this makes it extremely important that implementation of Clinical Performer include a detailed communications plan to reach out to physicians proactively. This includes having respected Press Ganey clinicians, like our clinical practice experts, assure physicians (in the presence of the CEO, CFO and COO) that the data reports are intended only to identify potential opportunities for improvement. Any actions based on the data should only be taken after full root analysis of the causes for the observed variances in performance. The root-cause analysis must involve the physicians, and will look for reasons that are related both to physician decision-making and hospital processes. The analysis will also resolve any attribution issues that might be present. Working through this introduction and implementation need for Clinical Performer is an excellent example of how Press Ganey is much more than a provider of data, but a partner with our clients to improve.