There is a lot of talk in HM circles right now about quantifying such nebulous medical phrases as “meaningful use” and “healthcare reform.” A phrase heard less often, but potentially just as critical to HM’s future, is “physician engagement.”
A prod to help define the latter comes from Kelly Caverzagie, MD, an academic hospitalist in the division of hospital medicine at Henry Ford Hospital in Detroit. Dr. Caverzagie and staff from the American Board of Internal Medicine (ABIM) set out to attach some sort of metric quantification to that engagement, then determine what impact it had on QI programs. Hence the aptly named study to be published in the October edition of the Journal of Hospital Medicine: “The Role of Physician Engagement on the Impact of the Hospital Based Practice Improvement Module.”
Before joining Henry Ford in 2007 as a hospitalist and evaluation research specialist, Dr. Caverzagie had worked as a contractor with ABIM, completing a two-year fellowship at the University of Pennsylvania in Philadelphia. He remains under contract with ABIM, which still pays a “small portion” of his salary. That relationship and Dr. Caverzagie’s hospitalist-tinged view of evaluation techniques piqued his interest in the engagement issue.
“The physician needs to engage in the process,” Dr. Caverzagie says, defining that engagement as “active enrollment and doing it for the right reason. Just enrolling in it doesn’t make quality improvement happen. You actually need to be engaged. And then … there is added value.”
The study focused on 21 physicians who completed their Maintenance of Certification (MOC) to remain current with ABIM guidelines. The hospital-based practice improvement module (PIM) is a Web-based platform developed by ABIM that “allows physicians to use nationally-approved, hospital-level performance data to complete the module” as part of attaining their MOC.
Each of the doctors in Dr. Caverzagie’s study completed their PIM by January 2007 and were interviewed anonymously about their experience. Interviews were recorded and transcribed to better verify responses. Nearly all of the subjects found the PIM useful (n=17, 81%). But with more questioning, the authors determined that how valuable the module was viewed depended on how involved the physician was in its completion.
—Kelly Caverzagie, MD, academic hospitalist, Henry Ford Hospital, Detroit
“The impact of completing the hospital PIM is mediated by the degree of physician engagement with the QI process,” the authors conclude. “Physicians who become engaged with the hospital PIM and QI process may be more likely to report successful experiences … than those who do not become engaged.”
Dr. Caverzagie and three ABIM staffers understood the limits of their effort, which breaks little new ground but piles on further evidence to prove the efficacy of getting hospitalists and other physicians more engaged in QI. A sample size of fewer than two dozen anonymous physicians allows for too many variables to consider the data indefatigable, so Dr. Caverzagie leaves it up to such regulatory and advocacy bodies as ABIM and SHM to determine whether and how to make systemic and process changes that encourage more involvement. “I don’t know if you can force engagement,” he adds.
His team created a set of definitions to showcase how different physicians with different attitudes experience hospital PIMs differently.
The most successful category is defined as “active engagers,” physicians who exhibited personal involvement. Eight of the 21 physicians, or 38% of the sample population, fell into this grouping. Ten physicians (48%) fell under the heading of “passive engagers,” a somewhat ironic category in which physicians reported negative experiences even as they documented what they felt was the knowledge gained from their hospital PIM. Finally, the authors tagged three (14%) “non-engagers” who “documented no evidence of QI learning and reported little impact from completing the PIM.”
Correspondingly, case studies highlighted in the study showed that “active engagers” took advantage of existing QI resources and staff at their respective institutions. They sought out staff leadership and fed off positive hospital cultures where they existed. One physician said it was “surprisingly easier to begin and initiate a quality improvement project than thought.”
One “passive engager” described their previous QI experience in terms of mandates handed down from administration, although several in the subcategory acknowledged they learned new skills or new information about how QI programs operate in their hospital. There also was some dissatisfaction in this category about the leadership shown by institutional staff.
Still, Dr. Caverzagie expresses optimism with this middle grouping, the largest statistically. “QI learning occurred despite the presence of multiple barriers,” the authors wrote.
In the least successful category—the non-engagers—several physicians interviewed said they didn’t need QI projects or were unsatisfied with a past experience, so they didn’t bother to try again. One physician declared, “We’re at a terrific level right now,” despite a hospital baseline performance measure of 5% compliance for percutaneous coronary intervention in less than 120 minutes.
To be sure, all of the groupings were at the mercy of internal and external factors—hospital culture, perceived relevance, institutional bias, and access to QI leaders among them. What remains to be studied is how to overcome those hurdles. Dr. Caverzagie says more work is needed to determine just how effective PIMs can be. He thinks the next stage for the modules could include more quantifiable metrics, which would be reported and then analyzed to “take doctors to the next level.”
“The vast majority of physicians, hospitalists in particular, are very interested in improving the care that they provide for their patients,” Dr. Caverzagie says. “They’re just not necessarily sure how to get it done. A challenge for our profession is to try to find a way to facilitate becoming involved in activities.”TH
Richard Quinn is a freelance writer based in New Jersey.