As a long-time hospitalist, I have a vision that one day, our specialty will be the "brains" of the hospital, the preeminent driver of acute care quality. As practitioners of internal medicine, hospitalists have a holistic understanding of the human body. And as hospital-based practitioners, we know the processes, pathways and relationships that keep acute care moving forward.
But as a new specialty, we have a lot to prove. If we don't add value and deliver great care, we're going to be looked upon as interns, not internists. The onus is on us to step up and earn the respect of colleagues and administrators.
Like most hospitalist groups, ours receives a mountain of data from our hospital on patient satisfaction, length of stay, case mix index (CMI) and other quality metrics. However, I feel these measures don’t tell the whole story. Many of the factors that make our group successful (or not) are intangible — things like communication, transition management and collegiality with one another. I also feel that if hospitalists are going to drive quality across the entire hospital, we need to begin with ourselves.
To this end, our group implemented a unique peer review program. In this post, I'll describe two of our initiatives and offer tips for building an accountable culture where peer review can flourish.
Individual Physician Report Cards
Given the federal government's growing focus on physician quality, it's probably only a matter of time before individual physician performance data is posted publicly. So creating physician "report cards" for our group seemed like a natural step— not to mention pre-emptive preparation for the future. At present, CMS doesn't mandate reporting of specific quality metrics for hospitalists, leaving us free to set our own success criteria.
The report card we created covers objective metrics written into our group's hospital contract such as HCAHPS, length of stay (LOS), CMI and percent of discharges completed before noon. However, it also includes some peer-reviewed measures determined solely by our group.
For this six-month cycle, we decided to focus on:
- Quality of sign-outs
- Citizenship (engagement, willingness to help colleagues)
- Communication with staff and patients
- Appropriate use of resources (labs, radiology)
That's where peer review comes in. Twice a year, each hospitalist confidentially reviews five colleagues (and is reviewed by five). As medical director, I compile the group and individual results and then provide feedback to each physician.
Now as you can imagine, doctors are a little nervous about having their individual performance data available. So to ease everyone's anxiety, we're taking small steps toward full transparency and accountability. For now, we're focusing on group data and reviewing our overall performance at monthly meetings. Physician-level data is confidential and isn't shared with colleagues.
As a next step, if the group agrees, we could tie distribution of our site surplus (money we receive based on group performance) to individual report card performance. To keep things fair and transparent, we would choose one to two metrics that can be accurately and easily measured during a given period. High performers on those metrics would receive a larger share of the bonus.
Care Concern Line
When I first became medical director, physicians often came to me to report concerns about other physicians. It was frustrating that they didn't feel comfortable to take their problems directly to the person in question. Nonetheless, it was positive in the sense that I heard what was going on. I felt that by formalizing the process and rolling it into peer review, we'd gain valuable insights about our functioning as a team.
One problem with this informal "reporting" system was consistency. Typically, incidents would reach me after the fact, and only then if the physician happened to run into me in the hall. This left no opportunity for a quick response, nor could I easily discern patterns over time.
To help our group become more systematic in addressing issues, we instituted a care concern line (CCL). Now when physicians see a problem, they can call a dedicated number that forwards to one of the medical directors. All concerns are addressed and documented promptly.
The CCL lets us troubleshoot in real-time. For example, let’s say a hospitalist wants antibiotics ordered for a patient he's admitting from the ED. He enters the orders but the floor nurse fails to initiate them. The next morning, he realizes the antibiotics were never given, and the patient's care was delayed.
The hospitalist calls the CCL and describes the problem to the medical director, who immediately contacts the nursing supervisor. Problem-solving takes place while the hospitalist, nurse and patient are still around to answer questions. Once a resolution is reached, I provide feedback to the reporting physician, explaining what happened and what will be done differently going forward.
CCL documentation has also proved valuable to the hospital administration. At our monthly joint operations committee meeting, we review incidents with the hospital administration to look for recurring problems. In a few cases, this has led to systemic change. (For example, the hospital canceled its contract with a habitually unresponsive on-call specialist.)
While peer review has generally been well-received by our team, I think it's wise to tread gently during implementation. It's very important that your group view it as a joint improvement project — and not a means of gathering information that will be used against them. Before rolling out peer review, the medical director needs to have the team's trust and build a culture where openness and transparency can take root.
So how do you lay the groundwork? First, make sure your team's basic needs are being met. Physicians who are unfairly scheduled or compensated have neither the drive nor the motivation to engage with improvement initiatives. And they probably won't trust a leader who allows such inequities to persist.
Another important step is to cultivate engagement. Readiness to tackle quality issues comes from the overall growth of both the individual physicians and the group. One way to speed up this process is by hiring highly motivated individuals. This isn't always easy given the shortage of available hospitalists. But when I'm interviewing a new physician, I make it clear I'm not looking for a clock-puncher or a warm body. I'm looking for a leader with a passion for the career he has chosen and the desire for involvement.
Growing as a Tribe
While our peer review program is relatively new, I believe it's already prompted some positive changes. Rather than handing off minor issues to the leadership, team members are increasingly comfortable approaching one another with concerns. In the 5 Stages of Tribal Development
, we're moving from "I'm great" to "We're great." And it's very exciting to see.