This last weekend my wife and I enjoyed the visit of an Interested Reader and his wife. It was a short visit. They arrived late on a rainy Saturday afternoon. They left too early for a walk on Sunday morning. We did have time for a great conversation in front of a warm fire in my living room and over a great meal at a local inn before suffering through the first game of the Red Sox and Astros in the ALCS.
My guest has spent most of the last forty years managing, studying, and teaching physicians and physician leaders about medical quality. I had a question for my friend that had been on my mind for some time that I wanted him to try to answer based on his broad professional experience. He not only lives and teaches about medical quality, he is frequently asked to evaluate and comment on the quality programs of a wide variety of medical organizations across the country. I thought to myself, “Who better to ask my question?” Before I reveal the question that I asked him, let me give you some background on my thought process.
Some years ago when I first attended the IHI’s annual meeting in Orlando in December I was exhilarated by the opportunity to be with so many like minded individuals. To be among 5,000 other healthcare professionals who are just as excited as you are to hear Don Berwick speak is a moving experience. As I was more and more involved in the quality conversation in my own practice I began to wonder just how seriously the broad “rank and file” of the practice was in the conversation. Don Berwick had been our colleague. He was the Vice President of Quality at Harvard Community Health Plan in the eighties before he became one of the founders of the IHI. At an almost subconscious level I began to have concerns that many of my colleagues were not “against” the quality efforts we were trying to launch, but they were not necessarily involved nor were they even indicating their support in any demonstrable way.
When Don used his opportunity as the Keynote speaker at the IHI to introduce the concept of “Era 3: The Moral Era of Healthcare,” I was exhilarated by his magnificent speech, but I detected just a little sense of bewilderment in the audience as he explained the nine steps and the transformational ideas in Era 3 to the large audience. Just to remind you of those nine steps:
- Stop Excessive Measurement
- Abandon Complex Incentives
- Decrease Focus on Finance
- Avoid Professional Prerogative at the Expense of the Whole
- Recommit to Improvement Science
- Embrace Transparency
- Protect Civility
- Listen. Really Listen
- Reject Greed
I imagined some generalized discomfort with “abandon complex incentives.” Almost all of the incentive programs I could think of for individuals and even institutions had quality incentives. Did he mean abandon pay for performance and other merit and metric based financial systems? He did say stop excessive measurement. Were not the quality payments dependent on measurement? The next item on the list almost sounded like something I would hear at church that no one took seriously: “Don’t worry about the budget. God will provide what we need.” Don’s version was just a straightforward admonition to “Decrease Focus on Finance.” The seed planted in my mind as I was listening to Don on that December afternoon would take a few years to germinate and eventually blossom into the question I asked my friend last Saturday. I do remember asking myself a question as he finished the list with “Reject Greed.” I wondered to myself as I left the auditorium, “How many of the 6,000 professionals who have heard this speech will have the professional and managerial courage to present this concept to their colleagues when they get back home?”
In a recent post I raised the question of why the concepts presented in Crossing the Quality Chasm seemed to be struggling for acceptance over seventeen years after they were introduced. You might remember reading:
The U.S. health care delivery system does not provide consistent, high quality medical care to all people. Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge–yet there is strong evidence that this frequently is not the case. Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care we now have and the health care that we could have lies not just a gap, but a chasm.
You might remember when I presented that quote from seventeen years ago I wrote:
It is amazing to realize that many children who were born while the work was being produced, and the ideas it contains were being debated, are now in college or will be soon. It has been a long time, and the problems that were identified as issues in the late nineties remain largely unresolved today.
That concept about how long change takes has bored its way into my brain and has focused the concerns that I was really not able to completely admit to myself when I first heard Don Berwick lay out his concerns, his analysis, and his suggestions. I do remember asking myself that day in Orlando, “How would the average physician or nurse react to these ideas?” Now as I am considering the conversations that I hear about compensation, the burden of reporting on hundreds of metrics, the challenges of falling revenue, the realities of inadequate staffing, and the personal and organizational issues of burnout, I am wondering, “Just what percentage of physicians and nurses think about the quality journey at all during any busy day?” Are they so busy with other things that the efforts to improve quality have drifted to the bottom of their list of priorities?”
As we were enjoying our fireside chat, I asked my friend what he would estimate as the percentage of physicians in the country who were actively involved in the quality movement. We chatted about the different environments of practice across the country. Is a busy clinician in a small Midwestern city without an academic medical center in an environment that promotes participation with other physicians to work on quality? Does another healthcare professional in a small New England town where there are concerns about a dearth of specialty support have access to a quality structure that presents an opportunity to think about “quality?” Does either have the time to think about the personal commitment required to begin to consider, or be involved with the transformational work necessary to practice with a focus on quality for individuals or populations? Just how concerned with quality is a young academic doing clinical trials in an academic medical center? I had an estimate of the percentage of involved physicians in my mind and wanted to know what his impression was. After thinking about my question for a few seconds he said, “Maybe 5%?” My response was, “I was thinking maybe 10%.”
Obviously it’s an issue of sample selection and numerators and denominators. I was basing my guess on my experience with the crossover between efforts at continuous improvement, population health, and quality in the organizations with which I have experience either in practice or as a board member. As we talked my friend’s number made more sense to me. There are over 900,000 actively practicing physicians in the country. 90,000 engaged physicians would make a real difference, especially if they joined forces with nurses and other healthcare professionals. It is my bias that nurses care at least as much, if not more, about issues of clinical quality as do physicians. As I thought back to the 6000 people listening to Don Berwick talking about “Era 3” I realized that no more than 50% of them were physicians. Those 3000 MDs in the room that day were less than 0.3% of all physicians in the country. They all had a very big job to do if we were going to spread the word in a way that got traction.
My friend and I sat there for a few minutes not knowing what to say next. We concluded that Don Berwick had been “preaching to the choir.” I asked my friend what he thought the reason was for the apathy about quality that we sensed was the reality in many practices today. My friend suggested that maybe the conversation about burnout had slowed the progress on our quality efforts. We shrugged our shoulders and moved on to another subject.
Later it occurred to me that a study of history reveals that some efforts to induce large scale social change do eventually make some progress after a very long period of gestation. I wished that I could say that examples of fully completed efforts were the civil rights movement, issues of equity for women, and a better distribution of the benefits of a progressive society. As with the effort for quality in healthcare, there has been progress on all those issues, but there is still a long way to go on all of them.
Over roughly the same time period that we have talked about quality as a systems issue there has been a conversation about medical professionalism. You might be aware of the effort that culminated in a Physician Charter in 2002. To quote from the ABIM Foundation website:
In 2002, the ABIM Foundation, in conjunction with the ACP Foundation and the European Federation of Internal Medicine, authored Medical Professionalism in the New Millennium: A Physician Charter. The fundamental principles of the Charter are the primacy of patient welfare, patient autonomy and social justice. The Charter also articulates the professional commitments of physicians and health care professionals in the modern era. This seminal document has since been endorsed by more than 108 organizations and over 100,000 copies have been distributed.
Let me suggest that you download the PDF that is available on the website, but just in case you don’t, I will point out that the charter has nine key points that are listed under “Professional Responsibilities.”
- Commitment to professional competence.
- Commitment to honesty with patients.
- Commitment to patient confidentiality.
- Commitment to maintaining appropriate relations with patients.
- Commitment to improving quality of care:
Under the quality bullet we read:
Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patient safety, minimize overuse of health care resources, and optimize the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions, and systems responsible for health care delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care.
- Commitment to a just distribution of finite resources.
- Commitment to scientific knowledge.
- Commitment to maintaining trust by managing conflicts of interest.
- Commitment to professional responsibilities.
I think that it is noteworthy that the charter on professionalism came out just after Crossing the Quality Chasm was published. I can’t think of any physician I know who would not be upset if I were to suggest that there is a flaw in their professionalism. I know that these are ideals and objectives and that no one is perfect, but I also know that there is work that we have collectively ignored. What do those of you who are working hard everyday to improve the quality of care suggest that we do to reduce the barriers to success and recruit more of our colleagues to the quality effort?
