Dr. Phil Brown
Central Vermont Medical Center sets new quality standards for physicians
BERLIN – Nearly a decade ago the Institute of Medicine electrified the public and the medical community when it reported that as many as 98,000 patients die in hospitals each year from preventable medical errors. “To Err is Human” ignited widespread debate about the quality of care. Hospital administrators, physicians and academics agreed that quality was important, but there was less agreement about what quality meant or how to achieve it.
When Dr. Philip Brown was recently named vice president of medical affairs at Central Vermont Medical Center, he made quality management – evaluating, measuring and improving the quality of health care delivery – the heart of his new job. “Quality is a passion for me,” he said.
“One of the struggles that physicians have with getting their arms around this thing called quality is that quality is kind of like pornography,” Brown quipped, echoing Justice Potter Stewart. “We all recognize what it is, but trying to define it is not so easy.
“You recognize quality physicians when you meet them. You probably have a pretty good idea when you walk out of that office, that I’m in the presence of somebody who is my advocate, who is competent, who knows how to talk to me, and who is going to look after my welfare. That’s quality,” Brown says.
The problem today, according to Brown, is that doctors are having quality indicators “foisted” on them by government agencies like the Centers for Medicare and Medicaid Services.
He cited the example of the standard for treating community-acquired pneumonia. Medicare mandated that within four hours of entering the emergency room, patients with pneumonia be given a specific antibiotic.
It’s no secret that giving a patient with pneumonia the antibiotic early is a good practice, Brown said, and in fact, the hospital does it nearly 100 percent of the time.
But he argued that the four-hour window was artificial. Some research indicated that the antibiotic should be given within four hours, while other studies set the limit at five or six hours. In fact, the guideline has now been changed to six hours.
Since most doctors knew all along that the window for administering the antibiotic was six hours, the Centers for Medicare and Medicaid Services lost credibility, their guidelines were perceived as bureaucratic and many doctors reacted negatively to what seemed to be arbitrary standards imposed from above.
Brown noted there’s no evidence that top-down mandates improve patient outcomes, so he is using a bottom-up strategy to bring about a “paradigm shift” in the way quality is pursued. If doctors are given the opportunity, he maintains, they will strive to improve their performance on their own.
Physicians are competitive, Brown says, and they are motivated by the “herd mentality” – they don’t want to perform less well than their peers. When they set goals for themselves and measure them, “We can see improvement a lot quicker – maybe in months.”
Take physician efficiency for example.
When Brown was director of the emergency department, a job he held from1994 until he assumed his current role, he found some doctors argued that they were slower because they were more empathetic and took more time with patients. Meanwhile their colleagues were “drowning” in patients, he said.
When the emergency department got electronic medical records, Brown was able to collect data on the number of patients seen per clinician per hour. He made a graph, identified physician data points with letters and took the graph to a staff meeting.
Before unveiling the graph, he gave each doctor the letter that corresponded to his performance point and instructed the doctors not to share the letters with anyone.
“Before you turn over the letter, tell me where you are,” he told them. All but one thought they were pretty fast. But when they turned the letters over, “There were three gasps,” Brown said. Two of the doctors came to him afterward and asked how they could improve their speed; they felt they were dragging their colleagues down.
In 2001, the Institute of Medicine released a report called “Crossing the Quality Chasm: A New Health System for the 21st Century.” It provided a road map for reforming the nation’s health care system and called for “consistently delivered, evidence-based care.”
In 2007, the effort to improve health care quality received a shove from the Joint Commission, a nonprofit body that accredits healthcare organizations. On January 1, it began implementing radical new “credentialing and privileging” standards for certifying the competence of doctors who practice in hospitals.
Instead of being evaluated every two years at the time they are reappointed, doctors’ performance would be reevaluated on an ongoing basis. While the commission didn’t specify what “ongoing” meant, John Herringer, the associate director the standards interpretation group said it meant more often than once a year. Central Vermont Medical Center will evaluate doctors every six months.2
The new standards, said Dr. Robert Wise, the vice president of the commission’s standards and survey methods, “will go beyond procedural competency, and we will move away from the idea that privileging is done by exception – meaning that ‘no news is good news’: If we don’t hear anything about the practitioner, obviously things are going well and they will receive their privileges. These standards are specifically built to challenge that and move into a much more evidence-based process.”
Brown’s strategy for bringing about the “paradigm shift” is to engage his peers in defining quality and determining how to measure quality’s outcomes in their own specialties.
In June, more than a dozen physician chiefs of the hospital’s sections, that is, departments – orthopedics, internal medicine, general surgery, gastroenterology and others – took part in a retreat where, with the help of a consultant who specializes in quality improvement, they considered how to improve patient care and measure the improvement.
The hospital will do the measuring and provide feedback to the physicians. “Our CEO’s mantra is, ‘To have quality improvement, you have to measure it,’” Brown said. “That’s the mantra that’s going to go to our docs. I may think I’m the best physician in the world, but if I don’t measure it, those are empty words, so there’s an onus on the doc to prove that.”
The consultant, Dr. Mary Hoppa, presented a physician-designed model – a pyramid – for thinking about health care quality. The base, or foundation, was recruiting good physicians.
Next came communicating expectations and encouraging physicians to accept them. Emergency department physicians might be told they are expected to make sure all patients admitted with pneumonia get antibiotics within four to six hours of coming through the door, Brown said. “Why?” He cited the evidence for the expectation: “Because national data show that patients who get a delay in their antibiotics beyond that four to six hours suffer complications that patients who receive it don’t have.”
The next layer of the quality pyramid was measuring doctors’ performance against the expectations: Did the ER doctors give antibiotics to patients with pneumonia within the prescribed time frame none of the time? 50 percent of the time? 100 percent?
Then doctors must then be given feedback about their performance: “Out of 20 patients you saw with pneumonia, 18 of them got that antibiotic within four hours and two of them got it within four hours and 20 minutes. That’s not too bad.’ That kind of feedback is important,” Brown said, “I may think I’m a great doc, but you know what? If I can’t prove it by measuring some degree of performance, it’s probably empty words.”
Finally, if a doctor is not performing well, he has to be helped to “get up the high-performance curve.” In the case of a doctor who doesn’t care about improving his performance or refuses to comply with directives, “That’s a corrective action kind of thing,” Brown said.
Later Hoppa led the doctors through the process of developing a six-part “report card” that not only measures quality of patient care but also includes issues like communications and professionalism. Does the doctor introduce himself when he meets his patients? Is he courteous? Does he instill confidence? Does he use mouthwash?”
Five of the six report card components – medical knowledge, practice-based learning and systems-based practices such as using a registry to collect, analyze and compare data about patients with chronic conditions – apply to all doctors. The sixth is specific to each specialty.
Brown says he and his colleagues are “trying to put legs to” the report card which he estimates will take 18 months to complete. They are using a national tool to measure patient satisfaction but are developing criteria for the various specialties themselves.
For the past nine months, Dr. Anthony Williams, an internist and past president of the medical staff, has been helping develop the criteria. He visited the sub-sections and asked the ear, nose and throat doctor, the head of the emergency room, the head of the anesthesiologists, ‘“Give me some criteria that you think is a good way to judge doctors in your specialty.’
“It’s hard to do,” he said. (What should be looked at to determine whether a dermatologist is doing a good job?) “It has to be criteria that you can measure. And then, what is an acceptable level of performance?”
In the past, Williams said, “We simply looked at all deaths. If anybody died in the hospital we would pull those charts and look through everything to see if it was somebody performing badly that caused the deaths. It was not the best way to look at quality.
“We have some flexibility in what we look at,” he noted, adding that to know what they are being judged on helps doctors accept the criteria. “If all the family practitioners and internists know that we’re going to be judged on what percent of our patients with high blood pressure are well-controlled, that helps. If you’re an outlier and only 20 percent of your patients are controlled compared to everybody else who has maybe 50 percent controlled, you’d probably want to know that.” The family practitioners and internists are already gathering the data.
Other challenges are determining what constitutes an acceptable level of performance and what to do when someone’s performance falls below that level. “People’s personal lives do degenerate periodically,” Williams observed, “and doctors are not immune. Personal lives go to pot, so people’s concentration – things just get fowled up, and you have to catch that. I think (the evaluations) will improve care.”
Williams believes physicians will buy into the report cards. “You want to do it well. Physicians are pretty discriminating. We want a good system,” he said.
He stressed that the purpose of the evaluations is to help doctors improve their skills. “You have to help correct somebody if they’re not being professional in some way and work with them collaboratively, not penalize them. The idea is to help them out if they fall below some accepted level of performance – we work with the doctor to improve that situation.”
Despite his personal enthusiasm for quality improvement, Brown knows that the transition to the new era of performance evaluation represents a difficult and uncomfortable change for many doctors.
His goal is to develop a team culture, where physicians serve as resources for each other. “I want to move this to a medical institution of transparency,” he declared. “I think the best medical institutions are willing to look at the good, bad and the ugly, and look at it hard in a compassionate, empathetic way.”
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