There was one part of my presentation, however, that clearly got physician attention. Every time I talked about Medicare’s Hospital Value-Based Purchasing (HVBP) Program, it was clear that most physicians had no idea what it was. I had a slide that detailed what Medicare at the time was specifically targeting, including safety indicators, quality core measures, and patient experience HCAHPS data. I described the process, formerly referred to as “pay for reporting,” in which hospitals had 2 percent of Medicare reimbursement withheld subject to voluntary submission of quality core measures and HCAHPS data. I described how eventually this would transition to a pay-for-performance program where hospitals would receive payments only by meeting specific benchmarks. Physicians were paying very close attention indeed to this part of my presentation. I could tell many had never heard about the HVBP Program.
I understood very clearly that we needed to educate physicians about what was going on in the healthcare environment and why their role in helping to manage it was vital. The HVBP information directly affected physicians. This was not just another hospital initiative; it was personal. At the conclusion of one of my talks, chief of staff Joseph Hahn, who always watches audiences as they listen, concurred that the message was really resonating.
I revised my presentation to show the three specific questions patients were asked regarding how well physicians communicate in the hospital environment. Now this part of my presentation really got their attention. I soon recognized that physicians truly did not know about or understand the government-sponsored survey mechanism by which patients were asked to rate physicians’ communication skills. They also didn’t appreciate that their individual performance would eventually be reported on the Internet and potentially linked to reimbursement. The epiphany struck them and me. One of the most important ways to engage the docs was simply to educate them about the new landscape and how they were personally going to be judged.
The responses from our employed group practice physicians and our private practice physicians were very similar. Neither group fully understood the implications of the government programs being deployed and how they would eventually affect physicians personally. While Cleveland Clinic’s employed physicians were easier to connect with because they had a clear reporting structure in a department or institute, it still required time and commitment to educate and engage them individually. Anyone who believes that employed physicians will just stand up and salute when you ask them to do something really does not understand physician culture. Employed physicians need to be convinced and engaged, just as private practice doctors do.
Engaging private practice physicians was somewhat more difficult. When I first became the CXO, we hosted dinners for our community hospital physicians to discuss the patient experience: what it meant, why it was important, how we were measured, and how we were all held accountable. These presentations were similar to what we gave to our employed doctors. We mostly discussed the HCAHPS data, which is a measure of inpatient experience. While the private practice physicians could certainly impact those scores through their behavior, hospital metrics are not individual physician metrics, so these doctors weren’t individually accountable. During one of the dinners, a very successful private practice physician remarked, “I don’t care about HCAHPS. That’s your problem, not mine.” In 2009, what could I say? He was right. HCAHPS was primarily a hospital issue, and there was little we could do to hold private practice physicians accountable. HCAHPS scores included how this particular doctor communicated with his patients, so it was not just about how the hospital functioned. But the hospital was the one penalized for not performing, not the private practice physician.
At a subsequent meeting, we addressed efforts to improve private practice physician communication with patients. We’d developed a physician communication improvement program for our employed staff and wanted to offer it to our private practice physicians to help them improve as well. This same physician said, “When I go over to your competitor, they put their arm around me and ask what they can do for me. When I come to your hospital, you’re always beating me up for my quality metrics. Where’s the thank you for bringing my patients to you?” It’s simply preposterous to suggest that we should be concerned first about making the doctors happy over monitoring quality outcomes for patients! But that exchange pretty much summed up our challenge.
The reality for private practice physicians, however, is changing. Medicare is creating strong levers in the form of quality reporting and transparency that will force hospitals to be more rigorous with regard to physicians’ performance. The risk for physicians is not just public reporting of quality and patient experience data and its link to reimbursement. They will be held increasingly accountable in four critical areas: outcomes, complaints, behavior, and the patient experience.
The World Is Changing for Doctors
We are moving from a volume-based world, where physicians are paid for doing more procedures and seeing more patients, to a value-based world in which physicians and hospitals are rewarded for how well they manage patients. Critical to this change is how we monitor outcomes. We presently have very little data on how well specific physicians perform, but progressively more data will be collected, and as a result, physicians will be held accountable for how well they deliver care. Those who perform poorly will lose money, will have their reputations defined by this performance, and could face organizational sanctions as hospitals are increasingly held accountable for safety and quality.
Regulatory agencies are listening to patients and investigating complaints about doctors and hospitals. In my state of Ohio, the department of health aggressively investigates patient complaints. One anonymous patient complaint about a doctor to the Ohio Department of Health or the Centers for Medicare and Medicaid Services can result in a surprise investigation of the hospital. Whether or not the complaint is valid, the investigation may reveal other deficiencies that could jeopardize a hospital’s Medicare Conditions of Participation, the minimal standards a hospital must meet to be reimbursed. The actions of one physician could endanger an entire hospital’s participation in the Medicare program. From an organizational perspective, this is obviously unacceptable. Hospitals can no longer afford to look the other way, as poor quality or disruptive behavior may place the organization at serious risk.
This new environment links physicians and hospitals much more closely. We’re dependent on one another for high performance and must work together to survive. The sooner physicians understand this—and the more we do to bring them into the fold to help us—the more successful we’ll be at navigating the difficult waters of healthcare reform.
All my talks with physicians now end with a slide that shows why paying attention to the patient experience is important:
1. It’s the right thing to do.
2. It’s how you and your family would want to be treated.
3. It’s patients’ perception of quality.
4. It’s the foundation of patient-centered care.
5. The government.
My list always starts with my preferred reason: “It’s the right thing to do.” Do we really need another reason? For the disbelievers and doubters, I end with “The government.” If you don’t think improving the patient experience is important for the right reasons, then understand that the government is now telling you it’s important and holding you accountable for improving it.
Today, the private practice physician I referenced earlier is one of our strongest supporters and advocates. He did not come along because of some sales pitch regarding why he should but took our efforts at education and came to better understand the importance. This physician is also engaged because we recognized him as pivotal. Identifying powerful peer leaders like him and helping them understand the importance of what’s going on creates strong allies in the war to improve.
Currently when I talk to physicians about changes in the healthcare marketplace, I still say, “This is the right thing to do,” and “It�
��s how you would want yourself or your family to be treated.” For the truly recalcitrant few, I also must occasionally make clear that unless they want to practice outside the American healthcare system on a desert island, they need to pay very close attention. I believe we’ve successfully taken the significant changes in the environment and leveraged them into a burning platform to get physicians engaged. Helping them to understand how these environmental changes will impact their self-interest is another critical engagement tactic.9
Transparency Is a Powerful Tool to Engage Physicians
Transparency is a powerful tool that is changing the face of U.S. healthcare, and it’s something that physicians are not quite used to dealing with. Just as individual physician communication metrics are relatively opaque at present, so are individual physician outcomes. But as the government pushes hospitals to collect more and more data on hospital and physician performance, communication and outcome performance will be posted online and available to all. Individual physician metrics that Medicare is developing will engender reputational risk and financial penalties. These environmental changes will create pressure on nearly every U.S. physician, whether group employed or in private practice.
Patients, businesses, and payers will have greater ability to view and analyze physician performance, likely leading to greater consumerism in healthcare. Patients will choose where to seek care based on a physician’s performance scores. Public reporting of data and its link to reimbursement will dramatically change physician marketplace behavior and the nature of the doctor-patient relationship. Physicians will be compelled to monitor their performance as it compares to national standards, which will impact reputations.
There have been some pioneering efforts in physician data transparency. Healthgrades was one of the first online companies to provide patients with a one-to-five-star mechanism to rate their experiences with doctors. This is inherently biased, as anyone can rate the physician, even nonpatients who may hold a grudge. Yet the ratings are in the public domain for all to see. Today, Healthgrades not only seeks patient feedback; the company queries public databases to compile information about education, awards, languages spoken, criminal records, board actions, certifications, sanctions, and malpractice. In addition, Healthgrades provides access information: where patients can be seen and what type of insurance is accepted.
One challenge of publicly reported data is that often the public doesn’t know that the data is available. Most healthcare consumers have no idea Medicare publishes hospital data online. The Massachusetts Health Quality Partners coalition found an interesting way to solve this problem by partnering in 2012 with the Consumer Reports organization to produce a special report regarding how patients rated Massachusetts physician practices.10 Some 64,000 adults were surveyed to obtain experience of care data for more than 480 adult and pediatric practices. Consumers rated the practices based upon patient communication, care coordination, familiarity with patient medical records, ease of appointment scheduling, and courtesy of staff. While leaders of the study touted cooperation of the various stakeholders, many physicians were unhappy with the transparency, as not all practices scored highly. Some took issue with using the same visual representation system (Harvey Balls) to rate both medical practices and goods such as washing machines and blenders.
Medicare has a public website called Physician Compare designed to provide individual physician safety, quality, and experience of care data. This will transform public reporting for physicians, because Medicare will establish the standards by which data is collected, including what is reported, how it is reported, and who participates. All physicians who work with Medicare patients will participate—essentially, all physicians. Furthermore, as with other Medicare programs such as readmissions reduction, value-based purchasing, and so on, reporting will be linked to reimbursement, so there will be financial penalties for nonparticipation.
Cleveland Clinic has heavily leveraged data transparency to drive improvement in our organization. For our 3,200 employed medical staff physicians, we are completely transparent with patient feedback. All staff physicians receive specific data regarding how inpatients perceive communication; the number and nature of complaints, including patient verbatims; and selected ambulatory scores. Every three months, all physicians receive unblinded departmental lists. Doctors can see their own data, as well as that of all of their colleagues. This complete transparency is unusual for such a large employed medical group, but it’s very important. The data transparency has introduced staff to an important tool for driving personal improvement, as well as helped prepare them for what is clearly coming in the national environment.
Physicians Are Vital, but Others Are Important as Well
When discussing environmental changes, physicians are often quick to point out that they are an essential piece of the healthcare puzzle. As one remarked, “Without doctors, there is no healthcare, so people better pay attention to us.” He was certainly correct, but I was quick to observe that without nurses, there is no healthcare either. In fact, there is no healthcare today without a lot of things and different people. Doctors are important, and they are often referred to as the engine of healthcare, but engines cannot fly by themselves without the rest of the plane. Alignment and engagement of physicians requires us to validate their importance. However, we’re also required to help physicians face the reality that it’s not just about them and that being the “engine” is not a license to do and say whatever they like.
Physician opinions are essential, and their voices must be heard. But physicians also have a responsibility to participate, listen, adjust actions when necessary to support the organization, and be productive participants to help the organization succeed. Physicians also need to keep their emotional intelligence in check. Clinical leaders who are not physicians, as well as nonclinical leaders in healthcare, tend to defer to physicians. I loathe sitting in meetings when a physician colleague confabulates about something he or she knows little or nothing about while the nonclinical leaders stay silent. However, once they are out of the meeting, they will talk about the physician behind his or her back. That is worthless participation! Nonphysician clinical leaders and nonclinical leaders must have the courage to challenge doctors openly.
If we’re willing to recognize physicians as unique and deserving of some deference, this requires us to ask something of them as well. Because of their impact and influence on patients and employees, physicians must hold themselves and their colleagues to a higher standard of behavior. Physicians and physician leaders should place greater emphasis on holding their peers accountable for doing the right thing. For example, we should never tolerate bullying. Doctors serve as role models for patients, students, nurses, and others in healthcare. Behavior that breaches that perception undermines the trust we place in physicians to provide care.
Physicians also must understand the subliminal influence they have on other leaders. Holding a medical degree does not impart expertise in managing healthcare organizations. Leadership teams must collectively recognize that everyone brings a unique perspective to the discussion. No one group should be allowed to dominate. I was troubled recently when a colleague and important member of our C-suite team said he did not always feel the doctors respected him because he was not a doctor. This is not the kind of environment we need to be successful.
There also must be a real effort on behalf of hospital leaders to engage physicians. When I spoke to a group of nonclinical hospital leaders from an outside institution about physician involvement in hospital strategy, they expressed significant frustration at the lack of physician buy-in. They complained, “Every time we make a decision that affects something in the operating rooms, it seems as though the physicians are always opposed to it. Nobody supports us!” I asked these leaders how they encouraged surgeon consultation and involved their physician leadership. They responded that key physician leaders were invited to all critical meetings but rarely showed up.
I disco
vered that their meetings were late in the morning when most surgeons had already started their operating room schedules. Private practice physicians, whose livelihoods depend on doing cases, are not going to reschedule patients or leave blocks of time open to accommodate meetings. The institution also held other meetings where important decisions were operationally vetted, but to which surgeons were not invited. This is where the real decisions were made. The so-called critical meetings were nothing more than presentations of decisions already made.
If we’re to be successful at engaging physicians, they have to be present for the real discussions. Inviting physicians to a meeting as window dressing and not involving them in a meaningful way is a superficial attempt at physician engagement that simply won’t work. If hospitals want to be successful at any strategic initiative, they have an obligation to get physicians to the table, and this may require a little accommodation and respect for the challenges their practices impose on their schedules.
Another effective tactic Cleveland Clinic has used to engage physicians is to identify early adopters and leverage them into physician-champion positions to drive new initiatives. Early adopters will have an interest in what’s going on and understand what you’re trying to achieve. They are the first to raise their hands to volunteer, or they may be ones who have a particular interest in a program peripheral to the patient experience. It’s also important to seek out the well-respected physician leaders. Not necessarily all who step up to volunteer are people you want driving your initiatives. Identifying a physician leader, even an informal one, who is well respected in the physician culture and who can be developed into a role model and champion, will have significant impact on improving physician buy-in. We tend to select the same people to help with various initiatives. But it’s imperative that we seek out a broad selection of physicians to participate. Experience is also critical. It’s the wrong choice to select new physicians, who may have more time on their hands, or physicians close to retirement and winding down their clinical practices. We make sure to take a cross section of busy clinical physicians working at the front lines. They command the greatest respect from their peers and have a much more current view of the clinical arena.
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