Engaging physicians is key to successful CM
Use lessons from peer review
Most professionals agree that the key to successful case management is learning how to influence physician behavior. But John Hinton, DO, MPH, vice president of clinical information management at Catholic Healthcare Partners (CHP) in Cincinnati, says how that is achieved often is very misunderstood.
According to Hinton, one critical area to which hospitals often fail to pay enough attention is peer review. "Peer review has gotten a bad reputation because often it is used only with problem doctors and not for routine surveillance of practice," he says.
One key component of peer review is that measurement of all physicians must take place consistently across standards, rates, and events, Hinton says. He contends that case managers and others should view that process as a "transformation."
By examining those three areas, he says, hospitals can view physicians’ practices objectively and perform critical assessments. That examination should take place on an ongoing basis as opposed to when an exceptional event takes place, Hinton emphasizes.
"That way, we are not accused of witch hunts," he says.
Hinton says he sometimes uses blinded data when engaging physicians on performance measures and that doing so often provokes criticism of their own behavior. "Physicians are often surprised about the comments they made on their own patient care," he says. "Peer review does not have to be punitive," he underlines. "It can be educational and instructive."
Identify goals and objectives
According to Hinton, hospitals perform better when they have clearly identified goals, strong administrative support, and ongoing feedback.
"You can’t be vague on goals and roles," he warns. "Whether it is case management or whether it is physicians, you need to be very specific about what you expect to see."
For example, when Hinton tracked the use of beta-blockers in acute myocardial infarctions, he was able to differentiate the hospitals that were able to meet their targets from those that did not. The motivation for physicians to improve is not that beta blockers are not often prescribed, but that beta-blockers make a difference and dramatically improve patients’ outcomes, he says.
Physicians’ views often are "myopic," he warns. "They view their practice one patient at time,’" he explains. "Good performance information allows a physician to see how populations of his patients are treated."
Using evidence-based care
Hinton says he does not always favor the use of care paths, which some physicians still consider to be "cookbook medicine." Rather, the aim should be to focus on broadly accepted interventions.
"Then we must make sure those things are happening," he says. "That is not cookbook medicine. That is evidence-based care."
Once that is accomplished, the next step is to establish a physician advisor, and case managers should play a critical role in that selection, Hinton says. "Case managers must feel they have strong backup with a physician champion’ behind them," he explains.
He emphasizes that the process must be very clinical, very pragmatic, and spearheaded by a physician. To help achieve that, Hinton sits down with physicians to help establish clear expectations. "You need to tell them what they need to be doing and how you want them to reform," he says. "You can’t just expect that they know what to do." (See graphs, below)
According to Hinton, the American College of Physician Executives sponsors physician educational sessions that focus on working with physicians and improving quality. The American Board of Quality Assurance and Utilization Review of Physicians offers similar programs.
He also recommends that hospitals periodically send physicians to spend a day in the office of a major payer to see firsthand how managed care operates.
According to Hinton, messages and expected interventions must be integrated into physician practices. He says integration can occur by measuring utilization of evidenced-based practices, providing feedback to physicians and incorporating the messages in rounds, residency training, medical department meetings, and grand rounds.
"I try to make sure these messages get out and live within the organization," says Hinton. He says that means constantly getting them in front of the medical staff. "If you are tracking this information through quality or medical and surgical committees, I think you must get the message out over and over again," he explains.
Interdisciplinary care teams
Hinton also has developed a video that explains how to work with interdisciplinary care teams. In his system, the interdisciplinary team assembles physician members from multiple disciplines to discuss a case and what is taking place unit by unit. "That has been highly effective," he reports. In fact, he says the interdisciplinary care team, along with performance feedback, use of physician champions, and quality oversight compose the primary success factors.
According to Hinton, physicians should run these meetings. He says that when he organizes a meeting, he acts as the external person to help ensure things run smoothly, but the physicians "own" the meeting. "That is key to moving things forward," he says. "Our job is mainly to facilitate."
Including board members on those committees also is very helpful because it makes the process more transparent, Hinton says. Including participants who are nonclinical helps enforce some accountability. But he cautions that often certain physicians are overused. "So often, we burn our doctors out," he says.
Hinton says another common mistake is to focus attention only on what might happen if something is done and to lose sight of what might happen if something is not done. "Many times, we are too worried that if we do something, something bad will happen, instead of what might happen if we do nothing," he says.
According to Hinton, the key ingredient throughout this process is collaboration, with a continued focus on quality outcomes for the patient. Often, he says, physicians will be inclined to function autonomously. "Effective feedback is critical," he asserts.
Hinton also reiterates that improved quality will result largely from effective tracking and trending performance. "A lot of that is how to understand data and process," he concludes. "Physicians are not big process people."
Finally, he says, hospitals must be sure to praise success and shine some light on the areas that are working. "We often tend to focus on the poor performers," he says. "We can learn from poor performers, but we can also learn from those who are successful."
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