Physicians may not alwaysrecognize the key elements of thequality process, but they dorecognize when things aren’t goingwell.1,2 “When I see the quality peoplecoming, I run the other way” is likelya comment that could be expressedby a physician or staff member. Itmight seem that they are missing the point, but the following is a sampling of complaints thatphysicians have made to me aboutbeing forced to engage in qualityprocesses they mistrust:

“I ordered a drug for my patientwhile she was hospitalized. Thepharmacy refused to fill it because it wasn’t in the hospital’s formulary. I reminded them that she is highlyallergic to soy and that the genericthey wanted her to take used abinder that was soy-based. Afterquite an argument, they relented. I’m not sure I understand how this is quality care….”

“I’m being dinged right now for patient complaints. I’m arheumatologist, and I’m pretty surethat my hospital doesn’t take intoaccount the amount of time I spendtrying to help my patients sustainquality of life while avoiding drug

dependence. Three patients havecomplained that I’m not ‘responsive’to their needs and suddenly thereports of hundreds of happypatients are ignored. It’s possible that these complaints may have anegative effect on my year-endcompensation. And the mediawonder why some physicians justgive in and write scripts for anyonewho asks for them.”

“Two years ago my cardiologygroup was bought by a local healthsystem. Since that time, we’ve hadjob reductions, education cutbacks,and budget limitations that mypartners and I feel are potentiallydangerous for our patients. Just lastweek, we couldn’t remove a patientfrom the ED and admit him becausewe couldn’t find a proper sizedgurney. Finally, my assistant literallysneaked one away from anotherdepartment. If you ask the hospital,we provide outstanding care, but Ididn’t go to medical school to plothow we’ll ‘steal’ the equipment weneed in order to take care of ourpatients. This isn’t my definition ofquality.”

Quality initiatives are oftenmisunderstood in healthcare settings.In too many hospitals, “quality”appears in plaques and brochures as marketing hyperbole designed toincentivize the troops and impressthe customers.3 These symbols ofintent don’t always provide anaccurate picture of the organization’scommitment or execution of patientsafety and satisfaction, according toCleveland Clinic CEO TobyCosgrove, MD. After all, he says,

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The goal of Physician Connection is to feature articles by leaders in the medical, legal and risk managementprofessions, and we believe you’ll enjoy the in-depthperspectives shared by our authors. We realize the practiceof medicine can involve both science and art. A patient’smedical history and treatment plan should be based on thepatient’s condition, appropriate guidelines and procedures,and the physician’s clinical opinion. Therefore, the viewsand opinions expressed are those of the authors and do notreflect the policy or position of PSIC.

Protecting Reputations ... One Doctor at a Time®

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PhysicianCONNECTION

By Kathleen M. Roman, M.S.

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Physicians and Quality Initiatives — Concerns and Solutions

“quality is more than just whetheryou live or die.”4 The actual work ofbuilding quality processes into thecorporate structure is too oftendelegated to a department ratherthan inculcated into the corporateculture.

Physician and Staff Supportis Key

When doctors and otherhospital staff don’t understand therationale behind quality processes,they may balk at makingrecommended changes. Critical tothe success of a QA initiative is buy-in from those the measure will impact. Traditionally, invasiveprocedures were performed in hospitals and exams and non-invasive therapies were performed in outpatient settings. The transfer of many types of treatment toambulatory care, especially inspecialty-specific organizations, was fueled, to some degree, byphysicians’ desire to escape theconstraints of hospital regulations.

Many doctors have complainedthat some quality initiatives seem tohave been designed to reinforce theuse of the dreaded “cookbookmedicine” or for financial reasons,rather than to improve patient

outcomes. However, if doctors aren’t aware of the foundations ofthe quality process, they can’tparticipate when these importantdecisions are being considered. Bymoving hospital-based services intotheir own practices, doctors felt theycould better control therapeutic andadministrative processes.

However, that hasn’t turned outto be the case. Case analysisconducted by medical malpracticeinsurance carriers and the NationalPractitioner Data Bank suggests an increase in the number ofstandardized hospital safetymeasures (e.g., infection control,informed consent education,formalized discharge instructions,etc.) that were not implemented/followed in ambulatory care settings,resulting in an increase in patientinjuries and subsequent medicalmalpractice lawsuits.5,6

In response to the sluggishimprovement in patient safety ingeneral, and with respect toconcerns about the dearth of safetypractices in ambulatory care, federalregulators and watchdogs, alongwith numerous citizen’s groups, havepressed for programs designed tohelp doctors implement qualityprocesses into their independent

practices. Taking into account theCMS report that over half ofpracticing physicians are nowemployed by health systems orhospitals, it’s important that patientsafety and satisfaction initiatives be pervasive throughout eachorganization—and that they arepracticed consistently andcomprehensively, regardless of thesetting of care.7,8,9 Organizations that cannot reach these goals willface financial penalties, denial ofreimbursement, and liability forpatient injuries as the AccountableCare Act changes access to,administration of, and provision ofhealth services in the U.S. Giventhese factors, it’s important thatphysicians have a workingknowledge of the quality processand that they insist that theircolleagues and staffs acquire thesame skill set.

It’s unfortunate that manyphysicians and other healthcareprofessionals have come to mistrustthe word “quality” because it isthose very tools that may help themlobby for legitimate improvements.10

By learning how to obtain accuratedata and assessing it, doctors canactively participate in conversationsabout the use of resources, changesin policy, and a myriad of importantdecisions that must be made inorder to keep the practice and/orhospital on an even keel. Withoutthis knowledge, the decision-makingprocess will sidestep them.

The Deming PhilosophyDr. William Edwards is known

as the leading quality guru in theU.S. His teachings inspired a qualityrevolution among Americanmanufacturers and consumers, andhis quality management work inJapan was a driving force behindthat nation’s economic rise.

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Deming’s “14 Points” are renownedfor its role in improving quality in theworkplace.

Deming’s 14 Points(Modified to relate to Quality Improvement in Medicine)

1. Create a top-down constancy ofpurpose regarding improvement.This has numerous implications forhealthcare. Without organization-wide commitment, even the bestprograms may fail. When all of thestakeholders are committed to thesuccess of the program and all ofthe necessary resources, training,and user support are in place,quality initiatives are much morelikely to succeed—and so is theorganization.

2. Adopt the new philosophy.Deming was a firm believer that the rules applied to management,as well as to everyone else. Top down leadership, he calledit. Everyone needs to make acommitment to quality. It isimportant to correct mistakes/delays immediately, work togetheras a team, and devise proactiveplans to avoid similar problems.

3. Cease dependence oninspection. If variation is reduced, there should be little need for inspection. If the entirehealthcare team were enabled toprevent errors, how much time,money, and grief would that savephysicians and staff? Rather thanwaiting until errors occur and thencorrecting them, the qualityprocess uses statistical evidenceto develop processes that preventerrors in the first place.

4. To the extent possible, utilize asfew suppliers as possible for anyone item. Because multiplesuppliers mean variation, andbecause it’s more difficult to

monitor quality when one is usingnumerous vendors, hospitals andmedical practices can save money by contracting with vendors who have proven theirreliability. With less variation inequipment, it becomes easier to train staff, to reduce user error, and to promptly identifymalfunctions.

5. Improve constantly. The quality- focused organization anticipatesthat the entire team will constantlyseek opportunities for improvement.Quality improvement is an active,ongoing process, not a one-time orscheduled “set” of projects.Quality is a journey, not adestination.

6. Institute training on the job.Lack of training—including teammeetings, re-education, reminders,and other tools to help learningbecome a permanent part of theculture—leads to variation amongworkers. Shortcuts, oversights, anddisinterest are forms of variationand they can lead to patient injury.

7. Institute leadership. This drawsthe distinction between leadership(which focuses on vision andmodels) and supervision (which

focuses on meeting specificdeliverables). Leaders need to actquickly and listen to supervisors.

8. Drive out fear. Managementthrough fear is counterproductiveand prevents workers from actingin the organization’s best interest.Efforts to encourage healthcareworkers to “speak up” areespecially important as the healthsystem seeks to encouragecollegial partnership throughout the service process.

9. Break down barriers betweendepartments. Increase andencourage two-waycommunication. Eliminate silos of authority. All departments areinterdependent and should see oneanother as customers in producinggood results. Tribal warfare (“Weknow you’re short staffed, butwe’re just much too busy to sendanyone to help you.”) neverimproves quality.

10. Eliminate slogans. Slogans don’tprevent mistakes. No one wakesup in the morning and thinks,“Hey, I’ll go to work today andorder the wrong medication.” Itisn’t the human who errs. It’s theprocess they’re engaged in thatisn’t working. The process fails the person, rather than the otherway around. Instead, provideproven methods of quality control.

11. Remove numeric goals.Production targets andoveremphasis on financial goalsencourage shortcuts. In amanufacturing process, this leads to poor quality goods. Inhealthcare, it leads to patient injury and lawsuits.

12. Remove barriers to pride ofworkmanship. Appreciation of the contributions of others iswelcome in any human endeavor.A group shouldn’t bother callingthemselves a team—unless theyreally act like one.

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13. Institute education and self-improvement. Anyone whoworks in healthcare should seehimself or herself as aprofessional. The mark of anyprofession is to master a body of knowledge—and then tocontinue to build on it for the restof one’s career. Personal growthis essential to a healthy career—and a successful organization.Encourage and provide avenuesto self-improvement.

14. Transformation is everyone’sjob. No job or individual is toounimportant to contribute to the success of the organization.The roles played by othersshould never be disrespected.(See Point 12). Physicians should clearly define qualityexpectations and have in place a management structure that will continuously take action tofollow the preceding 13 points.

Deming’s 14 Points have beensuccessfully implemented bythousands of companies in manycountries. Data collected by theseorganizations for over nearly 60years, have proven time and againthat they do work. Improving qualityreduces expense and increasesproductivity and market share.

Everyone’s talking about qualitythese days, but that doesn’t meaneveryone’s on the same page.Utilization of a quality improvementapproach to patient safety andsatisfaction is a great place to start.As Deming said: quality is what thecustomer says it is.

1 McKee, A. P., Health Care’s Dirty Secret:Physicians Don’t Wash Their Hands asOften as Other Caregivers.JCPhysiciansBlog. The JointCommission. Sep. 04, 2013.www.jointcommission.org

2 Field, J. Most Providers Don’t Know the Level of Quality They Provide, ButAssume It’s Excellent. The AdvisoryBoard Company. Care TransformationCenter Blog. March 5, 2014.

www.advisory.com/research/care-transformation-center/care-transformation-center-blog

3 “What Clinical Quality Really Means in2014.” Toby Cosgrove. Presentation.Nashville health Care Council. April 28,2014.

4 Ibid. 5 Webster, J. S., King, H. B., Toomey, L. M.,et al. Understanding Quality and SafetyProblems in the Ambulatory Environment:Seeking Improvement with PromisingTeamwork Tools and Strategies. Agencyfor healthcare research and Quality(AHRQ).

6 Freundlich, N. New Study Focuses onMedical Errors in Outpatient Settings: A“Wake Up Call” for Doctors. Health Beat.June 11, 2011.

7 Performance Measurement. NationalCommittee for Quality Assurance (NCQA).www.ncqa.org/HEDISQualityMeasurement/PerformanceMeasurement.aspx

8 Accreditation Association for AmbulatoryCare. www.aaahc.org

9 Leapfrog Group Names 2013 TopHospitals. Leapfrog.www.leapfroggroup.org/policy_leadership/leapfrog_news/5125813

10 Braunstein, G. D. Hospital AcquiredInfections: A Costly, Lethal Scourge ThatWe Must Labor to Wash Our Hands of.www.huffingtonpost.com/glenn-d-braunstein-med/hospital-acquired-infections;b-1422371.html

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