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This month, Joel Mattison, MD, a member of Hospital Peer Review’s editorial board, offers tips for bringing physicians on board for hospital quality initiatives. He is the physician advisor in the department of clinical resource management and medical director at St. Joseph’s Hospital in Tampa, FL. St. Joseph’s is a 900-bed hospital comprising a children’s hospital, a women’s hospital, and a psychiatric section.
Mattison describes St. Joseph’s vision of quality as processes that exceed "reasonable or useful expectations. It’s a moveable target," he says. "As we reach for it, it manages to just barely exceed our grasp each time. But at the same time, we seem to be jumping higher and reaching farther. What was good yesterday is not sufficient for tomorrow, and we must be ever moving in this pursuit."
Instead of mincing around the ever-present self-interest of physicians and other health care workers, Mattison views it as a fact of institutional life. Check out his practical suggestions for using it to improve patient care:
Q. One of the challenges quality professionals continually face is that of engaging physicians in hospital-based quality initiatives. From your experience, what kinds of incentives will hook them?
A. The first thing all physicians say when you approach them with this challenge is, "Well, you’re just trying to make money for the hospital." We try to get our physicians to understand what’s in it for them. We try to show them how the quality processes they learn at the hospital also can help their office practices and even the face-to-face management of their patients.
An example is the use of examination and management (E/M) codes. It takes good documentation to true grade your codes. When physicians really understand documentation, they also do more accurate coding in their offices, and their personal incomes can rise — not with upcoding, but with right coding. We’re trying to teach them how to do that.
We want their case mix index (CMI) to measure the true level of their patients’ illnesses. That means they shouldn’t have a CMI of 1, because that’s a pretty well person. When their patients are really sick, we want them to have a CMI up toward 2. This reflects comorbidities, complications, and other problems. That pays the hospital more through Medicare because it’s a multiplying factor.
But it’s not just for us. We want them to look good by having a high case mix, around 1½ or so, to reflect that their patients really need to be in the hospital. We want them to have a bell-shaped curve, with a small number at each end (levels 1 and 5); most of them in level 3; and a few in levels 2 and 4. To show what happens when they don’t, we tell them about the one physician who said, "Well, I’m going to beat this. I’m never going to have a problem. I’ll code all of mine as level 2." And so he did. And Medicare audited him for the quality of his practice because it said he couldn’t tell the difference between a sick patient and one with no problems.
Q. Besides upgrading processes in their office practices, are there other incentives for physicians to participate in hospital-based improvement projects?
A. If physicians understood and properly evaluated and documented the illnesses of their patients, that would almost be enough. One consultant explained that it could mean around $15,000 a year to the average family practice or internal medicine practitioner. The reimbursement system is set up to pay the hospital or physician for taking care of a young, uncomplicated patient with one illness. When that is increased by two or three comorbidities, such as diabetes, hypertension, and renal failure, with complications and age added on top of that, then a physician has a higher index for that patient. That index has a factor that’s used to multiply the hospital’s payment from Medicare. It makes quite a difference. Also, when HMOs sign up physicians, they like to see their CMIs and other data to determine their average lengths of stay (LOS).
Physicians definitely like to be associated with a hospital that enjoys a good reputation in the media and in published scores. They’ll sometimes participate in programs that save time and make them more efficient. They’ll frequently buy in to attempts to get better than expected results for patients and for the institution. They also like to know that some of the money they save is spent on modalities that eliminate barriers and move patients toward an early and beneficial discharge.
Although we have to be careful not to engage in gainsharing, I think it helps, every now and then, to tell doctors, "We just bought a new CT scanner for the emergency center because you needed it, and the money you saved us helped with the purchase. The scanner will help you move your other patients through the Emergency Center more quickly. And if they need to get to the operating room, perhaps you’ll be able to get them there more quickly, also."
I repeat that while you can’t share your gains with the physicians, it’s nice to let them see that the hospital responds to barriers by maintaining the infrastructure.
Q. What’s guaranteed to turn doctors off from quality initiatives?
A. Doctors are turned off by the impression that all of our quality talk is only about increasing the bottom line for the hospital. "Doing something for the hospital" never appeals to them. If we’re to have their support, they have to see that it’s mutually beneficial.
Q. Let’s imagine for a minute that regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations or the Health Care Financing Administration gave hospitals a one- or two-year "bye" from reporting obligations. Would hospitals refocus their measurement activities on processes that more accurately reflect the quality of inpatient service?
A. I think we’d measure the same things we measure now: Patient satisfaction, physician satisfaction, staff satisfaction, 30-day readmission rates, infection rates, morbidity and mortality rates, LOS, CMI, and charges per patient per admission. If our LOS is short, we especially like for our 30-day readmission rates to be low. We like to look at charges per patient, patient satisfaction, low rates of incidents like falls, etc. A high LOS provides a patient more time to develop bed sores or infection, or to fall, or to encounter medication errors. I’m not saying these are common, but it’s obvious that the quicker you get out of the hospital, the less likely they’ll happen. So we consider LOS as a quality thing as well as cost-saving. And physicians buy into that one, too.
Q. Any other measures you would consider important enough to keep, even if they were not regulated?
A. As I mentioned earlier, I think patient satisfaction is terribly important. You want patients to be happy — to feel that your hospital is a concerned, caring, friendly place to get well. There is also that difficult-to-measure factor of employee and staff morale. Patient satisfaction always follows employee and staff morale.
Q. Are physicians and other health care workers on the same page about the definition of a "good" quality initiative?
A. I don’t think that’s true in most hospitals. I think it’s the case in more institutions now than it was 10 years ago, but in many places, physicians and other health care workers make up different factions that go in slightly different directions. The administration is viewed with suspicion. The nonphysician staff view the physician staff with some suspicion. It’s very difficult to keep everyone working together.
And of course, self-interest is a big key to aligning all the groups on the same page. Each one needs to feel that it’s being heard and that the institution cares and has some concern about it and its responsibilities. This is extremely important. If team members are happy, and if their satisfaction is high with the institution and with each other, then the quality of care is good, the patients are happy, and the outcomes data are confirmatory. Patient satisfaction cannot increase without these interlaced fundamentals. Patient satisfaction is somehow a subjective complement of the objective indicators of quality.
In one of our programs at St. Joseph’s, we found that focusing on quality almost inevitably produced a simultaneous and untargeted reduction in cost. Doctors who practice quality medicine seem to focus on their patients, treating them one at a time, coordinating with case managers, and making rounds as often as necessary rather than the obligatory once a day. This meticulous attention to small detail results in quality of care and, frequently, in a dramatic, simultaneous reduction in LOS that comes almost as a by-product. Furthermore, it seems that spending more does not necessarily seem to have a positive correlation with high-quality care.
[For further information about engaging physicians in quality initiatives, contact Joel Mattison, MD, physician advisor, Clinical Resource Management, St. Joseph’s Hospital, 3001 W. Dr. Martin Luther King Jr. Blvd., Tampa, FL 33607-6387. Telephone: (813) 870-4933.]