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Reinvigorating stalled CQI efforts through physician involvement.

One rarely reads about CQI failures in health care, because most hospitals won't admit them, and some don't even recognize them. But preliminary market research suggests that failures may be the rule, not the exception. Of the 60 percent of U.S. hospitals now undertaking CQI initiatives, two-thirds report that the results of their programs have fallen below expectations.[1] That sentiment is also supported by objective data. If these programs worked well, the sheer number of hospitals involved should influence overall national quality/cost statistics. Yet average length of stay, health care inflation, and most other quality indicators have not deviated from their long-term trend lines.

A major factor behind the performance to date of CQI in hospitals is the failure of physicians to fit into the industrial model of CQI:

* The industrial model has "two types of people," customers and suppliers. Which category includes physicians?

* The model's major tenet is, "Do it right the first time." Most physicians and other licensed, trained professionals in a hospital would argue, even in the face of data, that they did it right the first time.

* An oft-repeated industrial quality standard is zero defects." Does that mean that physicians should be discouraged from admitting or operating on patients who might die?

These ill-fitting elements of the industrial model explain why medical staffs are not central to hospital CQI implementation. Consider these examples from our experience:

* A Boston academic medical center with salaried medical staff (presumably easier to manage than voluntary staff) designs its entire CQI program with no mention of physicians.

* A Chicago hospital excludes physicians from Day One because of fears that they will walk out of the introductory meetings due to sheer boredom, making employees feel the program is irrelevant.

* A Los Angeles administrative staff excludes physicians in order to prevent them from accumulating too much information. The concern: the more physicians know, the greater their power and the more numerous their demands.

The last example may be extreme. More generally, hospital top management teams that avoid physician involvement hold one or more of several opinions about their medical staffs'perception of CQI:

* They will resist and/or will be unwilling to accept responsibility for change. Instead, physicians will point fingers back at management.

* They won't care, and their indifference will bog down change.

* They believe that CQI is a complete waste of time and effort and serves only to distract people from their day-to-day jobs.

* They won't believe there's any benefit in CQI for them and that it will demand sacrifices of them.

These physician concerns are legitimate. However, the hospital must balance those reasons for avoidance against an unassailable fact: The large majority of resource use in a hospital can be attributed, directly or indirectly, to physician practice.[2] CQI cannot have a significant impact across an institution if such a major resource consumption issue is off limits, any more than the federal deficit can be reduced if tax increases and entitlement reductions are off limits. Under the circumstances, it is a tribute to the innate power of CQI that only two-thirds of health care CQI initiatives are stalling.

With so much at stake, there is simply no substitute for physician involvement, and this article offers four key strategies to achieve it. Using these strategies not only helps overcome the four most common objections, but may even make it possible to excite physicians about the process. Furthermore, some of the techniques can channel the likely defensive reactions of physicians into improving the CQI process and its outcomes.

Physician Resistance: When They Point Fingers, Don't Point Back. The classic physician refrain: You're asking us to [fill in a "sacrifice," such as get preadmission data to the hospital more expeditiously], while you have all those people sitting around in those mahogany halls. Why can't we do something about them?"

They may be right, or they may be wrong. The key insight is that they are asking a legitimate question. But the classic management response is best summed up in a comment about a doctor on a CQI team by the CEO of a Chicago hospital: "If he won't cooperate, we'll find somebody who will. And I hope he doesn't want any special favors from us."

Punishing the messenger - and the "lose-lose" nature of this particular response - will have a "chilling effect" on physician involvement in other CQI initiatives. To ignore, belittle, or gloss over the question, or to say, "That's not the agenda here," are other common, but highly inappropriate, responses.

The appropriate response is: "Doctor, that's not the agenda of this particular team. However, I understand your concern - all constituencies must contribute to waste reduction. Let us briefly deviate from the agenda to look at nonclinical areas." It is easy to address this concern, because there are tools available to answer that question.[3] Just as some databases can compare cost/ DRG, other tools, such as the Span of Central Benchmarks from the Healthcare Management Council of Needham, Mass., compare costs for executive offices, insurance, travel and other perks, etc.

No matter what the comparison yields, prospects for CQI are actually improved just by doing the analysis. If the administration is low cost, the physician's objection is overcome. If the administration is high cost, it can set an example for physicians by making some required changes. Not only is the question legitimate, but it also makes administrators empathize with physicians whose practice patterns are perhaps the raison d'etre for the CQI effort.

Medical Staff Indifference: Medical Director Leadership Needed. "Indifference" may seem less threatening than "resistance." However, indifference is usually a disguised form of resistance, by medical staffs too savvy to voice resistance. And indifference can scuttle a Ql team's work much faster than resistance can. Some examples:

* Physicians miss or arrive late for Ql team meetings.

* Physicians don't make themselves available to review the data ahead of time and undermine the analysis at the meeting by saying, "If I'd known you were looking at , I'd have told you to include to make the analysis meaningful."

* Agreements to change processes or practices are not followed through.

* A team physician concurs in a team recommendation but is unwilling or unable to "sell" colleagues on that recommendation.

* The department chair assigns a young or unknown physician to a team instead of a leader.

A classic example of scuttling an entire team can be found in attempts at agreement on prosthesis standardization. This is a typical Ql issue, because standardization reduces carrying costs, increases purchasing leverage, reduces space requirements, reduces error in surgical preparation, and, most important, simplifies the scrub team's job. Therefore, most orthopedics Ql team recommendations include standardization.

But what if the surgeon assigned to the team is a follower and can't get the #1 admitter to go along? The problem gets bumped up to the COO or the CEO, who faces a difficult decision: either antagonize the largest revenue-producer in what may be the most profitable service over a comparatively minor issue, or exempt the surgeon (and, by implication, anyone else who doesn't want to go along) and make the "decision" apply, in effect, only to people who would voluntarily comply anyway.

The insidious impacts of the latter decision far outweigh the loss of the benefits of standardization. The QI team is sent the following message: "You wasted your time and effort. Your group recommendations' - no matter how soundly based - are not as important as appeasing one physician. Stick to noncontroversial issues. I say CQI is important, but my actions speak otherwise."

A single incident can set CQI back years. Therefore, it is imperative that unspoken resistance taking the form of indifference be considered unacceptable behavior by the medical staff. Note that this statement does not say, "Go along with this effort because it's a hospital priority." Rather, it says, "We think this effort is critical. If you disagree, please tell us, and tell us why. All disagreements must be out in the open to be addressed." Communicating this message is the responsibility of the medical director.

Next, because the hospital is demanding a specific behavior of its medical staff, it must offer specific commitments in return. Here are some examples of hospital commitments that have used the impetus of overcoming indifference to generate an improved consensus about CQI:

* Incorporating the medical staff heavily in setting the CQI agenda.

* Sponsoring market research that shows that referring physicians have the same quality concerns about (in this case) open-heart surgery as administration does. This approach will work only where the issues are clear enough to show up in market research.

* Sponsoring clinical "line extension" studies in areas likely to yield more patients and more revenues for affiliated physicians.

* Running "mini-CQI" programs in a physician's ov,7n practice.

Furthermore, the medical director must commit to selecting the right physician(s) for each QI team. A "tough" person might be the best choice, slowing down the QI team but ultimately increasing the likelihood of consensus. The physician should also be known as an ambassador" - someone who can achieve buy-in from peers.

All these commitments, to be acceptable and affordable, will require the same kind of careful, politically astute negotiations that come with the territory" of executives at the interface of the administration and the medical staff. The need for those negotiations reveals the underlying reason why hospitals will tolerate physician indifference and not try to weed it out and channel it: It's not easy.

Physicians Think CQI Is a Complete Waste of Time and Effort and Serves Only to Distract People from Their Day-to-Day Jobs. Physicians are right ... in many hospitals. Here are examples of some specifics that help to form those opinions and suggestions for overcoming them:

* "It's a waste of my time." Although the "two types of people" model of CQI doesn't really fit hospitals, independent physicians look more like "customers" of a hospital than employees." The same teams that a hospital's employees are paid to be on (as part of their jobs), physicians pay to be on. Physicians have a strong interest in a hospital's decisions, but 10 meetings can cost a busy physician $1000-$2000 in foregone income. Their point of view is reasonable: Few customers" would jump at the chance to pay that sum to influence their supplier's product redesign.

Simply phrasing the issue in monetary terms reveals the answer: Be very selective in the use of physician time. On the meeting schedule, copy them in advance on the agendas and insist on their presence only when appropriate.

* "It's a waste of everyone else's time." One of the major complaints about CQI is the mind-boggling emphasis on training. There is a "quick-start" model of CQI that addresses this complaint - and generates faster returns than conventional CQI:

* Conduct an assessment of clinical, technical, managerial, and service quality to find the biggest problems. This contrasts sharply with CQI theory, which says that all areas can be improved. Finding the biggest problems makes more sense. It is easier to show results and people can use limited amounts of time and energy most effectively.

* Instead of training everybody and setting up dozens of teams, concentrate resources first on the biggest problems and train only the involved parties.

* Celebrate the results and generate demand for teams and training based not on management dictum but rather on employee enthusiasm.

At this point, widespread training becomes necessary, but it looks like less of a "waste" if results have been shown.

* "What do all these diagrams mean? They have nothing to do with medicine." Many terms (Shewhart cycles, fishboning, benchmarking) that make sense in industry - and that are accessible enough to be widely understood - make no sense whatever to physicians. And the jargon only intensifies the distrust. Focus on tools that are the most tangible, such as flowcharting, cost bar comparisons, and variance analysis. Focus on the tools for what they reveal, not for how they work. For example, a presenter, despite obvious pride in the achievement, shouldn't announce to a team: "Here is a fishbone chart displaying the root cause of all the problems with the admission process, which took a long time to do. I had to capture every action etc." Train presenters to say, "Let's look stepby-step at the admissions process."

A physician no more wants to hear how the tools were used than a car buyer wants to hear the salesman say how a car was built ("We had to locate the finest iron ore and carefully cast it ....").

Physicians Think There Is Nothing in CQI for Them, and That CQI Is Likely to Demand Sacrifices of Them. At least two issues lie behind this problem. First is timing. CQI is the longest term noncapital commitment that most hospitals make. Many physicians, by reputation, have a time horizon that extends through lunch. The medical education system stresses interventions." It is no surprise, for instance, that surgeons lose interest when they are told that three to five years will elapse before results are forthcoming. The solution is a "quickstart" approach to CQI, as recommended above.

The second issue is agenda. Some CQI projects (such as interdepartmental cooperation to simplify the admitting process) are done with physicians' input. Others (such as standardization of orthopedic supplies) are, in physicians' perception, being done to physicians.

The discussion of hospital commitments to the medical staff alluded to the possibility of running a "mini-CQI" for medical practices. Such a program would have three phases and take only a few months:

* A baseline service quality evaluation, using specific, measurable standards of service quality:

* How quickly are the phones answered?

* How promptly are new patients scheduled?

* How long do patients wait?

The trick is to focus the practice assessment on service quality issues that are also practice revenue issues. If someone calls to cancel an appointment, is a rebooking date offered? The answer, in 78 percent of cases, is no.[4] ("You don't want to reschedule, do you?" was one actual response.)

* Once issues are revealed, training ensues. Service quality training programs for physician staffs are inexpensive and require only a few hours.

* Follow-up monitoring against measurable standards invariably demonstrates improvement.

"Mini-CQI" programs raise not only revenues and service quality, but also employee morale and job performance. Few physicians retain their CQI skepticism after these programs. And, once again, the CQI program is actually improved, because physicians are supportive not due to management jawboning but rather because they have been voluntarily converted to the cause.


[1.] InterQual market research (n = 55).

[2.] Data from the Healthcare Management Council, Inc., Needham, Mass.

[3.] Lewis, A. "Too many Managers: Major Threat to CQI in Hospitals." QRB 19(3):95-101, March 1993.

[4.] InterQual survey of physician offices (n = 4,000+).

Al Lewis is Executive Vice President, Peer Review Analysis, Inc., Boston, Mass.
COPYRIGHT 1993 American College of Physician Executives
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Title Annotation:continuous quality improvement
Author:Lewis, Al
Publication:Physician Executive
Date:Jul 1, 1993
Previous Article:Informed decision making: the new paradigm.
Next Article:The private practitioner in hospital quality assurance.

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