Blue Cross and Blue Shield of Minnesota has signs in the new "Target Field" ballpark that hosts the Minnesota Twins home opener April 12, as well as two Blue Cross-branded first-aid stations that promote the Blue Cross "Do" campaign. "Do" video stories about people taking steps to improve their health will be shown on the scoreboard throughout the Twins' season, and CEO Pat Geraghty will throw out the first pitch at the Twin's May 28 game to promote the "Heart Walk."
Whether we particularly like it or not, physicians are accustomed to having our actions judged—by our patients and their loved ones, other members of the care team, and the organized medical staff of the hospital(s) where we have privileges. For many years, physician evaluation by the hospital and its medical staff came at periodic reappointment—every one or two years, was a somewhat basic, and was often a subjective validation of our perceived competence, technical skill and judgment.
More recently, The Joint Commission and other accrediting bodies and payers have established more stringent guidelines for the ongoing evaluation of the professional practice quality of each medical staff member, across all departments and services. Called Ongoing Professional Practice Evaluation (OPPE), the program features six core areas measuring a practitioner's clinical and behavioral competence. Evaluation is to be on a regular basis, such as every two, four or six months. This means more frequent scrutiny of physician practice patterns—and the outcomes of our practice of medicine—than ever before.
The Six Competencies in the Joint Commission Standards
Patient Care.Practitioners are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and managing the end of life.
Medical/Clinical Knowledge. Practitioners are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, as well as the application of their knowledge to patient care and the education of others.
Practice-based Learning and Improvement. Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate and improve patient care practices.
Interpersonal and Communication Skills. Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families and other members of health care teams.
Professionalism. Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward their patients, their profession and society.
Systems-based Practice. Practitioners are expected to demonstrate both an understanding of the contexts and systems in which health care is provided and the ability to apply this knowledge to improve and optimize healthcare.
Some physicians may not view this change as major or as a reason for concern. Hospitals have already been delivering a variety of performance management data to them for some time. But as regulations and medical practice in general have become more complex—and data have become more plentiful—having a positive dialogue regarding the specifics of a physician's practice as part of the organization's quality improvement program has become more challenging.
After all, by our very nature and the job we're challenged to perform, physicians want to be perfect and don't generally like hearing when we're not. None of us enjoys criticism. Also, being told that our method of practice is less than perfect means we have to experience change, which is typically a challenge for every human being. This is especially true for something as ingrained as an individual physician's (or a department's) daily practice of medicine.
Moving through the stages
Those hospital executives tasked with sitting down with a physician to discuss practice variations as part of OPPE or any other performance-improvement initiative will need to be prepared for the reactions they'll likely encounter. Thinking through the process ahead of time will help move the conversation toward a positive dialogue and acceptance for implementing change—change designed to lead to broader implementation of best practices and achievement of improved outcomes.
An incredibly useful model for coping with all types of change—or any news people don't want to accept, for that matter—has proven to be one adapted from the Elizabeth Kübler-Ross model on the stages of grief ("On Death and Dying"), developed in 1969. These stages are fluid; during the process, a person can go from a bargaining stage to denial and back again. So while predicting human behavior is not an exact science, the Kübler-Ross model is a useful foundation.
Stage 1: Denial. "This is not right! The data are incorrect!" In this initial stage, the data is in effect summarily dismissed. The most common summary dismissal is "this is just 'administrative' data." In my mind, the term 'administrative' is outmoded and relates to a former, less complex time—when five or so discharge codes were applied only for the purposes of reimbursement. Today, a discharge abstract contains 36, 64 or even more ICD-9 codes so that all co-morbidities and complications can be effectively captured. Coders have long since learned that this data is being used for public reporting, quality improvement and many other purposes.
Stage 2: Anger. "How dare you? Who are you to tell me this?" Don't be scared off of by this response. Expect it as a move in the right direction to the next stages. Remember . . . there may be a need to visit this (and other) stages more than once before positive and consistent forward movement is achieved.
Stage 3: Bargaining. The "Yes, but . . ." stage. "If you just had better data . . . if it were more clinical and less administrative…my patients are sicker and this doesn't take that into account . . ."
Here's where executives can engage in a discussion of the validity of the data and the risk-adjustment model to help move the practitioner to the next stage. For example, Premier healthcare alliance member hospitals can point to the fact that they are using the largest clinical comparative database of its kind, used by more than 600 facilities in North America. It includes inpatient and outpatient data, from all payers, representing one in every five discharges in the U.S. Even that kind of evidence supporting the data presented may not be enough. But this is a critical juncture in the road toward acceptance-having a dialogue about the data instead of a total rejection of it.
Frame the discussion in terms of how "we" can use the data to improve patient care quality and safety, while maintaining the effective use of hospital resources and the practitioner's time.
Stage 4: Depression. Practitioners don't typically spend much time at this stage, once they've gone through bargaining. They will either move on into the acceptance phase, realizing that they need to get on with the tasks at hand, or they will circle back immediately to anger and then further bargaining. Framing the exercise as one of quality improvement for the sake of providing exceptional patient care—rather than as an attack on professional competence—will hasten progression to the acceptance phase.
Stage 5: Acceptance. Now's the chance to move this practitioner and the entire medical staff in a more transparent process to not only satisfy the OPPE requirements, but more fully ingrain an organization-wide, ongoing professional performance improvement culture that they will support willingly.
What can be achieved?
The need to have an operational OPPE program has become a given. It's a Joint Commission standard for recertification and thus important to virtually every hospital. Having an effective OPPE program is another matter. Making an OPPE program truly effective requires framing it within the context of using information for improvement rather than judgment, and using "actionable" information to improve the lives of patients and staff alike.
More importantly, having a process and tools to effectively gain practitioner buy-in can and should lead to an organizational culture where physician performance reporting is part of a larger, transparent quality improvement process-where the organization can focus on delivering the highest level of care possible, rather than engaging in non-productive "grief" sessions.
Recognizing the inherent challenges of coping with change, providing "actionable information" and correctly framing the exercise in the context of institutional improvement will allow hospital execs to be prepared to deal with roadblocks that will inevitably occur along the path towards improved performance and outcomes. It will also afford the opportunity to accelerate an organization's overall performance improvement initiatives and results.
Richard Bankowitz is chief medical officer at Premier Inc. in Charlotte, NC. He may be reached at Richard_Bankowitz@PremierInc.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Surgeons are performing more dangerous, difficult, and expensive spine surgeries involving fusion rather than simpler less expensive decompression procedures, with far more mortality and complications.
Those are the findings by Richard A. Deyo, MD, and colleagues, who looked at adjusted data for all Medicare patients who had the more complex form of the surgery for spinal stenosis and found a 15-fold increase between 2002 and 2007, from 1.3 to 19.9 per 100,000 beneficiaries.
And life-threatening complications increased as well, from 2.3% from those having simpler decompression procedures to 5.6% for those having complex procedures, which also had longer stays and a higher rate of 30-day readmissions. Mortality within 30 days was .6% compared with 3%. Additionally, costs associated with the more costly fusion spine surgery were $80,888, compared with $23,724 for simpler decompression surgery.
Deyo, a researcher at the Oregon Health and Sciences University, and researchers at Dartmouth Medical School and the University of Washington in Seattle published their findings in this week's Journal of the American Medical Association.
"It is unclear why more complex operations are increasing," the researchers wrote. "It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just 6 years. The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications."
They suggested surgeons may believe more aggressive intervention produces better outcomes. Also, improvements in surgical and anesthetic techniques "may make more invasive surgery feasible when risks formerly would have been prohibitive. Financial incentives to hospitals and surgeons for more complex procedures may play a role as may desires of surgeons to be local innovators," they said.
Spinal stenosis is the painful degeneration of the lower spinal column that decreases mobility and weakens the legs. These operations numbered 37,598 in 2007, at a cost to Medicare of $1.65 billion in 2009 dollars, according to the report.
Interestingly, the number of spine surgeries actually went down slightly between 2002 and 2007, so the number of complex, more dangerous lumbar fusion represent a large portion of the costs.
The researchers also found geographic variations in the rates for spine surgery. "They suggest a poor consensus on indications for surgery or the choice of particular procedures."
Yet, they added "evidence for greater efficacy of more complex procedures is lacking."
The researchers concluded, "in the absence of compelling data showing better pain relief or function with more complex surgery, our results may suggest using the least invasive procedure that accomplishes clinical goals."
In an accompanying editorial, Stanford University orthopedic surgeon Eugene Carragee, MD, said Deyo's findings "do not provide explanations for the increase in complex surgery," which might be explained if patients had more extensive deformities.
"The diagnoses reported, however, do not support this 'ideal' explanation; 50% of these new complex fusion operations were performed in patients with spinal stenosis alone and no deformity."
Such "proliferation of risky and expensive practice beyond reasonable supporting evidence is commonly mentioned as a fundamental failing of medical practice in the United States."
More complex technologies for spine surgery are being used for patients "with little specific indication for the approaches and for whom there is good evidence that simpler methods are highly effective." Additionally, he noted, surgeon compensation for a simple decompression spinal stenosis is approximately $600 to $800, compared with complex fusion, which pays "10-fold greater."
The study by Deyo "demonstrates a definite human cost to this practice in terms of a clear increased risk of surgical mortality, major complications and prolonged morbidity associated with these more complex approaches [and] there is no evidence that these factors have been adequately considered" by surgeons performing the procedures, he wrote.
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached atcclark@healthleadersmedia.com.
Hospitalist programs could help all types of institutions, according to speakers at the pre-course of the Society of Hospital Medicine (SHM) annual meeting in Washington, DC Thursday.
"I couldn't think of one institution that wouldn't benefit from [a hospitalist program]; it's pretty universal," said Martin B. Buser, MPH, FACHE, partner at Hospitalist Management Resources, LLC, in San Diego, CA.
All institution types—large, small, urban, rural, community, teaching—could see advantages from implementing a hospitalist program, Buser added. Residency caps have contributed to an overflow of patients, which is one reason why the hospital medicine movement is considered the fastest growing medical specialty.
Despite variations in institution size, the need for hospitalists exists everywhere, according to Buser. With growing numbers of patients, resident duty hour restrictions, and reduced primary care physician time in the hospital, many institutions have turned to the hospital medicine model as a solution.
Despite similar needs, the infrastructure will be different depending on the institutional.
"It's crucial to get this right," said John Nelson, MD, FACP, FHM, medical director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, WA, and founder of Nelson/Flores Associates. The infrastructure of the hospitalist program should be balanced in workload, billing responsibilities, patient care, and even a social life, according to Nelson.
The most important thing before taking the dive of starting a hospitalist program is good leadership, including a medical director who acts as a champion for the program, Buser said. The hospital and the medical director can establish expectations for the program, and, therefore, set staffing levels to meet those needs.
New programs might fail if they are too ambitious and take on too many patients from multiple specialties all at once. Instead, Buser recommended setting the priorities for which patients hospitalists will take on first.
Even if practice administrators make the decision to utilize hospitalists, there's still the question of whether to employ or outsource to contract hospitalists. Most practices with hospitalists are employed by the hospital (40%), according to the SHM 2007-2008 Biannual Survey. Another 14% use local hospitalist-only groups.
For those starting new programs, there's no best employment model, said Buser. For those who aren't familiar with the hospital medicine concept, it might be better to outsource instead of directly employ, he added.
So when is the best time to start? There's no better time than now to start considering a hospitalist program, according to Buser.
"Years ago, we had more time because it was a foreign concept. Now, it's becoming a point of 'we want it yesterday,'" he said.
"The biggest challenge for hospitalist programs is accommodating for growth," Buser said about trying to stay ahead of the curve. "A conservative approach never pays off. It's always better to be a little overstaffed. The volume will come," he said.
Karen M. Cheung is an associate editor for HCPro, contributing writer for HealthLeaders Media, and blogger for HospitalistLeadership.com. She can be contacted atkcheung@hcpro.com.
By a slim majority, the Miami-Dade County (FL) Commission took the first step toward giving itself authority to create an emergency board overseeing the Jackson Health System. Proponents of the move cautioned they had no desire to install an oversight board now, but wanted to create a framework in case conditions continue to deteriorate at the financially strapped public hospital, the Miami Herald reports.
St. Joseph's Health System and Piedmont Healthcare have announced their intent to create a partnership that could lower their costs and expand their delivery of healthcare. The two Georgia-based hospital systems said they have signed a letter of agreement to enter into exclusive negotiations to create a "joint operating company." It remains unknown exactly what services such a joint operating company would provide, but it could include medical services or shared computer systems, officials told the Atlanta Journal-Constitution.