Governance for good relationships
Many hospitals and health systems have found a degree of success in improving quality and safety through new governance structures that set standards for every physician in the group.
The traditional medical staff structure, for example, is not one that works to facilitate coordination of care, says Wasserman. It's too big and unwieldy. He encourages his clients to develop smaller work groups that are designed to address a particular challenge "instead of having one system where every doc has his head under a single tent," he says.
Though hospitals are required by the Joint Commission and other accrediting and certification bodies to have a formal medical staff organization, Wasserman suggests limiting its official duties to those required by law: credentialing and review of inpatient quality measures.
And don't make the mistake of assigning your "high-revenue" physicians or the heads of very large practices to lead these efforts, he says. Leaders of quality and safety committees should have an economic stake, but if you really want a meaningful leader, "you have to find someone who has that understanding of the patient process and factors that drive quality care," he says.
Wasserman suggests looking for key physician leaders on the primary care side who care about their patient loads and understand the interrelationships.
"The degrees don't matter as much as their willingness to get engaged in some really definitive activity," he says. "It's not easy, but they're out there. Sometimes, young physicians are the best."
He cautions hospitals that giving up some authority is difficult, but that physicians will generally hold themselves to higher standards anyway, if given enough leeway.
"Often it's the hospital that won't give up authority," he says. "Sometimes giving up a little authority is the best way to get movement, and they'll see right through it if it isn't genuine."
Trinity's Murphy sees a lot of advantages of focusing on chronic disease because such patients need high levels of care, and because poor coordination of their care is one major reason healthcare can sometimes be expensive, and it relates to the quality of care received. As more evidence comes out regarding how the patchwork care coordination such patient populations receive increases the cost of care and hurts quality, Murphy says clinicians feel a professional responsibility, outside of economic incentives, to improve.
"Providers have really started examining the fact that we are incredibly expensive, and they know we can get better outcomes," he says. "They can do that by agreeing as clinicians on guidelines for clinical care."
Not only that, says Murphy, but the technological solutions to guiding patients through the care process are getting better and better.
"In some ways, technology is driving this," he says. "Now you have help in managing patients in a proactive way, with disease registry programs, by knowing what populations are at higher risk, where they are, and how to approach them. We didn't really have those clusters of attribution in the past. We didn't have the data to manage them better before."