Peer Coaching Engages Medical Practice & Ambulatory Physicians in Improvement

Added on Mar 21, 2019

Peer Coaching Engages Medical Practice and Ambulatory Physicians in Continuous Improvement
By Andrea Fitzgerald

Physician peer review and coaching are highly effective tools for quality assurance and continuous quality improvement. While they’re most commonly used in hospital settings, an increasing number of health care systems are using them to evaluate and improve physician performance across medical practices and outpatient care facilities.

Northwell Health Physician Partners (NHPP) and Atrium Health are among the organizations that have developed internal peer-managed improvement processes for their physician practice (NHPP) and outpatient clinic (Atrium) settings. According to Dr. Barry Goldberg, chair of the NHPP Physician Patient Experience Committee and chief of pediatric cardiology at Northwell Health’s Southside Hospital, and Dr. Tracela Vaden, Atrium Health’s medical director of patient safety, peer review and coaching has been the key to engaging physicians and physician leaders in performance measurement and continuous improvement efforts.

It seems paradoxical that physicians, who are committed to delivering safe, high-quality, patient-centered care, may be resistant to measurement and improvement efforts. However, there are several factors that contribute to physician resistance, including fear of being assigned blame for adverse outcomes and mistrust of the criteria being used to measure quality.

To remove these detractions from physician buy-in, NHPP and Atrium Health have leveraged peer review and coaching to support and empower providers to discern improvement opportunities in their own practices, as well as systems and processes across the organization when possible. This not only promotes cross-sharing of best practices and transparency, it also drives systemwide improvements, according to Drs. Goldberg and Vaden.

Giving Physicians a Voice

NHPP and Atrium Health formed a physician-led patient experience and quality oversight committee, respectively, in 2015. At NHPP, the goal was to advance the practice’s transparency initiative, whereas Atrium sought to advance its High Reliability journey.

Although the focus and structure of the programs put in place by the two organizations differ—the NHPP program is physician-initiated in response to patient experience issues, while Atrium’s program is system-generated to address safety concerns—they share a key underlying objective: to create and sustain an organizational culture that inspires providers to openly share any challenges they face and be proactive in seeking out solutions and better ways to deliver care. The point is not to improve one physician’s performance, but to improve the entire system’s ability to deliver care, Dr. Vaden stressed.

“We see ourselves as one medical practice at many locations. As such, we are dedicated to providing the same high-quality experience to all of our patients, no matter which of the 650 locations they visit,” added Dr. Goldberg. This shared commitment compels NHPP’s Physician Patient Experience Committee members to volunteer their personal time to offer peer-to-peer assessments and mentoring. “We want to support every physician partner in carrying out our mission of providing exceptional, comprehensive, and quality clinical care to our patients and communities,” he said. 

NHPP began publicly reporting physician ratings and comments in 2015 to advance that mission by helping current and prospective patients choose a provider that best meets their needs. A physician-driven appeals process that incorporates peer mentoring is essential to this transparency initiative. When reviewing patient comments before they’re posted, physicians have the opportunity to file an appeal if they believe the comment meets an exclusion criterion, such as including a description of their personal appearance. Physicians who initiate an appeal are given the opportunity to make their case at a face-to-face hearing with at least three peers from the Physician Patient Experience Committee.

“It is singular to NHPP that a peer-to-peer assessment can only be initiated by the individual physician, rather than being a systematic response to every negative comment,” said Dr. Goldberg.

Atrium Health also implemented a standardized peer review process in 2015. In this case, the process was embedded into the outpatient Patient Safety Program. According to Dr. Vaden, this nonpunitive and confidential process was designed to improve the safety and quality of care across Atrium’s outpatient settings by supporting and engaging physicians in change efforts.

“Care events” are submitted weekly by providers or another member of the care team or are taken from patient complaints for review. The patient safety review team identifies any trends in providers’ behavior or patient outcomes and evaluates processes and systems for improvement opportunities. If deemed necessary by a member of the review team or risk management, the case is sent to a reviewer on the Quality Oversight Committee (QOC) comprising physician leaders of each service line. At this point, service line leaders can involve the physician, other providers in that service line, front-line staff, IT specialists, organizational leadership, and others in the review process. “Whoever can help identify weaknesses in the process or system and then drive change is included,” Dr. Vaden noted. 

At both organizations, a face-to-face meeting between committee members and the providers begins with the former explaining who they are, what they do, and why they do it. They then ask the practitioners for their take on the patient visit or event under review. Both Dr. Goldberg and Dr. Vaden stressed that it’s important to ask for and listen to the physician’s perspective to ensure that they understand they are being included in the process and are not being punished. “This should not feel like being called to the principal’s office,” added Dr. Vaden.

The next steps differ between the two health systems, but they continue to center on communication, trust, and continuous improvement.

At NHPP, once the physician has presented their explanation for why the comment meets an exclusion criterion, the physician steps out of the room and the committee deliberates whether to uphold or reject the appeal. The physician is then invited back into the room to hear the ruling. If the appeal has been rejected (meaning that the comment will go live), the committee shifts from adjudication to mentoring. Since the overwhelming number of negative comments are made by patients who felt their doctor was rushing or disinterested, the committee frequently shares best practices for demonstrating empathy and other caring behaviors, according to Dr. Goldberg. This includes teach-backs, restating what the patient is asking, and offering written materials that detail topics discussed during the visit.

“It always comes down to pointing out the gap between the physician’s perception of his or her own practice and the patient’s perception, and offering proven approaches for closing that gap,” he said.

At Atrium Health, after the provider walks through the event with the reviewer, the reviewer determines whether the level of care met generally accepted performance standards with opportunity for improvement or did not meet performance standards, and develops improvement plans accordingly. 

In many cases, neither the issue nor the solution is provider-specific. When reviewing the death of a pediatric patient, for example, the QOC found nothing wrong with the provider’s care, but did find an opportunity to improve the triage process. This resulted in the creation of a customized triage process for complex pediatric patients, which has prevented treatment delays and improved the quality and efficiency of pediatric care across the ambulatory setting, according to Dr. Vaden.

The program has also resulted in initiatives that have influenced the entire health care system. Because of less restrictive regulatory oversight in the ambulatory versus inpatient setting, Atrium’s patient safety review team and the QOC are able to share and quantify challenges that are prevalent among providers across hundreds of Atrium’s outpatient care locations. This sparked an initiative to resolve the top 10 causes of lab-related errors, which resulted in a 55% reduction of such errors across inpatient and outpatient settings from 2015 to 2017.

NHPP has also achieved systemwide success through its peer mentoring process and transparency program as a whole, best represented by the overall increase in physicians’ star ratings. In August 2015, star ratings ranged from 3.6 to 4.9. In June 2018, every provider was above 4 stars.

Drs. Goldberg and Vaden insist that the greatest achievements of peer-managed improvement processes are difficult to quantify, and they credit their respective programs with shifting their organizational cultures away from being reactive and punitive to being proactive and supportive. “Four years ago, physicians may have only worked with their service line leaders when they were in trouble. But now physicians and service line leaders are recognizing each other as a resource and ally that they can approach with a problem. It’s a whole new perspective and partnership,” said Dr. Vaden.

“Before we began this journey, some doctors were prone to dismissing dissatisfied patients as unappreciative of their hard work,” added Dr. Goldberg. “Now our doctors are thinking proactively about how they can best meet their patients’ needs to enhance their professional practices and their relationships with patients.”