A program at VUMC is making significant inroads in helping physicians turn around their practices or behaviors after patients complain about them, either because of the doctors' actions or their clinical work.
If you are having trouble with your patients or not cutting it in clinical matters, you may get a visit from a "peer messenger." Often the news they bring isn't great.
And that's the idea.
Often, you don't have a clue you aren't passing muster, but the hospital has the data that shows you are not doing as well as you think. To help physicians get on track, The Center for Professional and Patient Advocacy at Vanderbilt University Medical Center in Nashville several years ago designed the "peer messengers" program.
The point is to keep physicians on track after patients complain about them, either because of the doctors' actions or their clinical work, before they become targeted for lawsuits. And the plan involves fellow physicians helping them. The messengers are physicians who you may see down the hall, in the cafeteria, or at board meetings.
"We don't come down on them with a ton of bricks, but we send a peer review team to say, 'Here's a heads up," says James W. Pichert, PhD, co-director of the medical center's Center for Patient and Professional Advocacy, which runs the peer messenger program. "This is holding up a mirror to the physicians, and it shows that 'this is your data of what you are doing.' It's not a gotcha. We always appeal to their great sense of professionalism."
Physicians who are named peer messengers are nominated by hospital leadership, undergo training, and represent various disciplines within the hospital. They interview and help counsel docs who are targets of patient complaints that may range from how they communicated with to how they were billed.
Generally, these doctors have not committed violations of their practice. In severe cases, where violations are alleged, lawyers likely would be involved. Instead, the docs that the peer messengers see have practices that are falling "outside the norm of expectations, or the norm of best practices," Pichert says. For the most part, these doctors "are absolutely unaware that they stand out in that way," he adds.
VUMC is finding that the peer messenger review process is making significant inroads in helping physicians turn around their practices or behaviors, Pichert says. A dozen other community and academic medical centers also are using a similar peer review process, he adds.
A four-year study which ended in 2005 evaluated 375 physicians deemed to be at "high-risk" for possible litigation. After peer messenger involvement, 64% of the targeted physicians had shown improvements in their work, Pichert and his colleagues report in The Joint Commission Journal on Quality and Patient Safety. About 19% of the physicians did not change their behavior, and 7% actually worsened, the report states.
In what Pichert called outright successes, 34% of physicians who met with the peer messengers for two years improved their "risk scores." The peer messenger's first visits averaged barely over a half hour, and follow up visits took less.
Overall, peer review is becoming an increasingly important element in determining physicians' conduct and helping them on the straight and narrow, whether it involves clinical quality or bedside manner.
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Although the Centers for Medicare & Medicaid Services provides guidance for managing complaints and grievances about physicians, "the value of such reports lie in what the organization decides to do with information thus learned," Pichert says. And that's where the peer messenger review process helps fill the gap, he adds.
It's also important for hospitals to stem patient complaints especially because of the link between them and litigation related to malpractice lawsuits, Pichert says. "There's a high risk of complaints generated by patients that lead folks to go to a plaintiff attorney. Then there's an unexpected outcome and it may be unnecessary," he adds.
A main element of a peer messenger review program, of course, is the makeup and structure of the groups themselves, which are formally known as the Patient Complaints Monitoring Committees.
During the period of Pichert's study, about 178 physicians—14 emergency and medicine physicians, 87 medical generalists, or specialists and 77 surgeons—agreed to be peer messengers. One or more physicians may represent the committees in discussions with doctors being reviewed. Then the committees meet to discuss courses of action.
The Peer Messengers "Widely Respected"
When Vanderbilt looks for peer messenger review members, they look for standardized qualities: peer messenger members were identified as being "widely respected" and "known for their commitment to professionalism, confidentiality and fairness," Pichert says.
And when the peer messengers meet with physicians, they ask them why patients complained about them in the first place. In the Pichert review, at least 48% of the physicians attributed their "high-risk status" to patient complaints related to systems or logistics problems. About 41% blamed their personality or communication style.
The peer messengers tap into data about specific behaviors or clinical outcomes used by the university's Center for Patient and Professional Advocacy (CPPA). They schedule "confidential collegial visits" with identified physicians to share data about their standing, compared to local and national CPPA norms related to the complaints. Data is shared with targeted physicians in a 'respective, non-punitive, nonjudgmental, and nondirective fashion," Pichert wrote.
The peer messengers are "willing to intervene with colleagues over an extended period of time," Pichert says.
If anything, the peer messengers are told to avoid any tendency to be "fixers" of problems. If necessary, they initiate a process for additional hospital intervention if they don't make inroads in helping the physicians.
Success Factors
To improve physician clinical work and behavior, two elements are among the most important for success, Pichert says: hospital leadership and the doctors under review themselves.
"Overall success of an intervention process depends not only on peer willingness and skill to provide feedback but also on leaders who will hold others accountable," Pichert writes in the report.
Ultimately, Pichert told me, it is "self-regulation" among the physicians themselves that matters most.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
