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Shaun Frost: Accountability Is Key to Hospital Medicine's Success :: Article - The Hospitalist

Shaun Frost: Accountability Is Key to Hospital Medicine's Success

From: The Hospitalist, May 2012

We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector.

by Shaun Frost, MD, SFHM

As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).
We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.
Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.

The Accountability Imperative

If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”

Essential to capitalizing on these performance- improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.

Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.¹ The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.
The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.
Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1
Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.

Accountability and Autonomy

Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.
Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.² He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”
Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.

Failure to Perform Not an Option

It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.
Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”
Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.
Dr. Frost is president of SHM.

References

1. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361;14:1401-1406.
2. Reinertsen J. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-995.

15%+ of Physicians Change Jobs Annually

SK&A has completed a study on the percentage of physicians relocating annually for a new job. According to their study titled Physicians on the Move, the 3 year average of physicians that moved to a new location or practice is 15.2%. This figure also includes those physicians that retired or passed away.

Summer is an interesting time in physician recruiting; most of the residency and fellowship graduates have identified positions but there are still a lot of experienced candidates interested in making a move, and 2011 candidates are ready to begin interviewing. This article is interesting because it reveals the rate of change of office-based physicians by practice specialty, and is targeting established and experienced physicians.

We have found a high percentage of physicians changing their first job out of residency in the first 2 years of practice. Often times new graduates are attracted by high reimbursements or a large salary, and once they have signed with a facility either the promises made are not kept or physicians change their motivating factors, such as location, case load, trauma call, and community amenities. However this article states physician stability and job change has decreased over the last 3 years.

According to the article from SK&A, data from their study suggests that the move rate of physicians has declined steadily in the past 3 years, indicating recent stability among the specialties surveyed. The rate has gone from 18.2% in the 2008 reporting period to 15% in 2009 to 12.4% in the 2010 period.


Read the full article in Healthcare Finance News, or click here:
http://www.healthcarefinancenews.com/news/study-more-15-percent-physicians-move-annually

Healthcare...the unspoken

Many have been lauding the current economic recovery plan.

I, however, fear that if the impending health care plan shows as little scope as the economic plan, being equally little more than a band-aid for a deeper wound, it won’t be good. It’s debatable if printing more money, creating more American insolvency, will pull us out of the economic crisis. Yet, to propose a trillion dollar health care plan without addressing what really ails us is lunacy. The bottom line is that the same issues plaguing our economy plague our health care. Both are the forums in which our social issues play out. Our country isn’t at a crossroads because of its economic and health care crises. It is at a crossroads because of its greed, its entitlement, its worsening lack of personal accountability, and its immediate recourse to litigation – all of which play out in the economic and health care arenas. If we wish to make a true change in health care, then all of our decisions need to be guided by the desire to avoid letting people, all of us collectively, regress into their worst behavior.

Beginning with personal accountability, I’ll share an interesting thing I heard in training. A colleague and I were in the ICU treating patients, and he remarked, “Everyone’s here because of a vice.” He meant it in jest, but it gave me pause. From smoking to drug abuse and addiction, to excess eating and shirking exercise, certainly a significant percentage of those whom we treat are sick fully or partially by their own choices. That definitely isn’t to say they shouldn’t be treated, but where is the accountability, and even, the payback into the system? If one takes away all personal accountability, as American society has done, then we’re left with many who never help heal themselves. It might seem confusing to analyze from where the decline in personal accountability came, but it may be quite simple. It’s a perversion of the American ideals of democracy and rights. With democracy, the goal is to make everything easily accessible to everyone, and while this is good in theory many people are not ready for what they want. People feel responsible for that which they put in good effort to acquire. So much nowadays is given away carelessly, with no effort really required to obtain, that it is an easy atmosphere for irresponsibility. Additionally, over the years, the concept of personal rights, an extension stemming from our original, wonderful preservation of civil liberties, went from being perceived as a gift, an ideal to which civilized societies should aspire, to a due. Consequently, many tend to absolve themselves of responsibility for their wellbeing, through their entitlement.

We wouldn’t be able to be so entitled if there weren’t, nowadays, some semblance of a guarantee in life. In the last century, with the advent of progress in technology and medicine, the multitudes have begun to count on things ‘going right.’ People have come, by virtue of modern advancements, to expect a guaranteed outcome – indeed, ‘perfection’ more and more. When anything falls short of that, they feel betrayed, angry, and want justice and compensation. Many often forget their own responsibility in their outcomes, forget that fate often intervenes independent of desire, and forget that perfection may be a mirage. Entitlement, a byproduct of rights fueled by this false semblance of a guarantee in life, is rampant in American medicine.

There are some solutions for curbing our wayward tendencies. For starters, we should develop sensible laws. Tough love laws should help encourage self-sufficiency and getting back on one’s feet. Concurrent with this, laws which counter, or discourage systemic abuse are necessary. Laws with proactive contingencies are also helpful to create incentive. Next, to help us shift our perspective, we should set a new media standard. It’s dismaying how low the overall quality of our media has become, with how often the same angle to stories is repeated – we tend to try and be as complimentary to ourselves as we can, rather than objectively self-critical. We don’t like to hear that we’re irresponsible, entitled, greedy, or unaccepting. Yet, all of us need honest media – we collectively raise ourselves to the level we’re given, and if we’re given substandard, inaccurate information, that is what we use to make decisions. A concerted effort should be made to inform well – this could be informally agreed upon by the big media players or codified more formally. Third, there should be an even larger push for palliative care. Americans have strayed from recognizing decline and death, even though it occurs to us all, and are consequently often unable to realistically assess outcomes. People must be re-familiarized with a sensible concept of mortality, and should be given assistance with recognizing and dealing with their own decline, through outpatient and inpatient protocols. As a final point, along with recognizing the state of the patient, real tort reform needs to be enacted, not just caps on damages. Lawyers should not be able to advertise to ‘recruit’ lawsuits, frivolous cases should be penalized, and defendants should be able to counter-sue if the case is without merit.

Finally, regarding that last ill, greed, it plays out in medicine in an interesting way. I don’t feel that most physicians are greedy; in fact I feel the field, overall, is quite ethical. The issue of monetary appropriation comes up mainly on the ‘opposite’ side in duly compensating physicians and their affiliates for their work. Physicians, as with all members of service industries – teachers, nurses, firefighters, police, and paramedics, for example, – should be well compensated. Physicians have been targeted for what they earn, but one should want those striving to do the best they can and take good care of others to be well paid.

America currently has malaise. Spending more money on treatment, without rectifying the essential problem, our shunning of personal responsibility, our entitlement, our recourse to litigation, and our greed, will simply be a cosmetic change. America through its citizens is extraordinarily open to change, is courageous and resilient. We need to be open to rectifying our destructive behaviors, which erode the effective and efficient provision of our care, as good, cost-contained health care should be available and affordable for every individual without bankrupting businesses, health care facilities, or our nation. Good medicine is that which promotes longevity of quality, and we need that now, to avoid becoming sicker.

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How to choose a Hospitalist practice

When looking for a practice, one can get bogged down with the mundane tails, thinking that they are the defining ones. Of course it matters where a practice is, city-wise, and hospital-wise. Of course salary matters. Of course contractual issues matter, like negotiating tail coverage, and non-compete clauses. But core issues are core issues – often standard from practice to practice – and not necessarily the deciding factors. Really, when it comes down to making a decision, I feel three independent factors may have make-it-or-break-it status,

The first is benefits. I can list a number of disappointing things I’ve seen regarding benefits. Some companies offer paltry medical insurance or have excessively high premiums for the insurance, making one wonder what the actual employer subsidy is. Some don’t offer short or long term disability, or make the physician undergo a waiting period for eligibility. Some play around with their 401K plans, not allowing you to contribute until you’ve worked a certain period (since when was deferring saving for retirement an incentive for working for someone?), or withhold their match until the end of the year preventing you from being able to take earlier advantage investment-wise. Some also vest you gradually, like indentured servitude. With retirement, one should be able to contribute from day one, receive one’s match in a timely fashion, and be vested immediately to recoup that for which one worked – especially given the phenomenal amount of money made by physician billing, as well as today’s uncertain economic climate. Again, regarding medical insurance, dental coverage can also be paltry, and eye care non-existent. It’s interesting that physicians might be shortchanged by their employers regarding their health care. In short, benefits are a crucial to deciding for or against a practice. I feel one should opt for a practice with comprehensive, fair, and reasonably generous benefits.

The second is flexibility, in schedule and in practice structure. People choose the hospitalist field because of the flexibility in schedule. My ideal is when needed time off can be put in for in advance, and a tailored schedule created. It may take more work on the part of whoever is doing the schedule but it is worth the effort in terms of physician satisfaction in getting needed days off, and not having a run of too many days. Five days on and off, and seven days on and off are seen relatively frequently, but I don’t think these are as great. Some people probably prefer the predictability, but such schedules often entail having the same people work together day in and day out, and although this ‘team’ approach can work well if there is a good team, I’ve seen it backfire and be stifling. Of note, a tailored schedule also means having varied options for part time. Life is demanding and people should be able to adjust their work life accordingly. Flexibility in practice structure means avoidance of micromanaging. Physicians are often well-trained enough to do well on their own, and the main guidance they need is in adhering reasonably to changing standards, and doing correct billing. Looking constantly over their shoulder as if they were still in residency may adversely affect retaining independent-minded doctors.

The last is how nights are covered – preferably by a night doc. As much as we all (contractually) agree nights need to be covered, and we have a certain level of masochism derived from medical school stating we must always go the extra mile, and do the hardest work, our instincts tell us we’d rather not do nights if we don’t have to. It’s a godsend to have night coverage, and good night doctors are worth their salt and should be paid as such.* Most day physicians have no problem seeing a good night doctor receive higher compensation, because they know how hard nights can be, and how radically the practice of night medicine differs from day medicine – you can’t just switch easily from one to the other, and good night doctors have a knack for what they do. Unfortunately, administrations often don’t understand this, and since they feel they can get nights on the cheap by having day physicians rotate through night coverage, that’s how they run things. Again, though, given the profits generated by physician billing, there is really no reason to forgo hired night coverage. I suspect there would be less burnout, if practices actively recruited good night physicians, and paid them handsomely for their work. I also suspect there might be more nocturnists, if groups were willing to pay for them.

Again, it’s important to look beyond the basic issues, and evaluate the ‘frills.’ Most practices are going to be relatively comparable in basics, and it’s the perquisites that create the nuances that we ultimate act on. Benefits, flexibility, and how nights are covered are definitely key issues which can enhance or detract from a practice, but which the average doctor, starting out, may be less inclined to focus on, because he or she is caught up in comparing salaries, and negotiating contractual issues. The key is to get a complete picture, do thorough comparative research, and at the end, as always, trust your gut.

Article by: Hospitalist--M Pujari, MD