The hospital process response is the most useful to me because for every quarter that we send letters, there are multiple hospital processes that are modified as a result of this response. It is always fascinating to me because almost all of these measures have had good quality-improvement teams, but there are always missed subtle issues or unintended consequences. Because physicians respond quickly and often passionately, the urgency to fix these processes is present, hence facilitating rapid change.
Kill Them with Kindness
When I suggested sending these letters a few years ago, many on the quality staff cringed. Their reluctance was not unfounded: My original letter was a tad abrasive. I have toned down the letter, even to the point that I am now asking for help rather than directly pointing the finger: “I need your help in reviewing the following patient’s chart. In an initial review of quality indicators, a deficiency is noted. This may be because of simple oversight, or the patient might have had a contraindication for therapy for which we cannot find documentation. A physician must document all contraindications. Please review this chart as soon as possible, and if you feel this deficiency is in error, please let me or one of the outcomes managers know immediately. This deficiency has not yet been reported to the federal quality-improvement organization. We may be able to correct the error prior to final submission.”
The last line of the response attaches responsibility: “If we do not hear from you, we will assume the deficiency stands.”
This whole plan is part of a campaign in our hospital to personalize quality data. Recently, several studies have shown that consumers do not review quality data. Other evidence is increasingly backing up the “embarrassment” approach, as some would like to label my methodology. I prefer to call it the “personalizing method.” Physician education these days is largely based on case studies and the evidence-based approach. Personalizing quality data combines both, and might be the ideal approach to taking great leaps in quality.
Some experts have lamented this approach, but I can tell you that when I received two letters regarding the omission of offering a patient with heart failure weight-monitoring instructions, I quickly changed my approach and now make sure that the residents and nurses are giving those instructions. Initially, I was a little defensive about it, but I did the right thing and made modifications. Personalizing does work, and we should embrace it more fully.
It is not easy to personalize. Our present systems—or lack thereof—require abstracting and the review of written notes to achieve high levels of accuracy in personalizing. Without these high levels of accuracy, it is difficult to engage physicians with this data. The future is in electronic capture, but none of this is perfect, either. Hospitals must develop and hone systems to catch physician assignment during multiple interventions of a typical patient stay.
The cost of all this is unknown and most likely significant. But one could easily imagine a tremendous improvement in quality.
My message to hospitalists and hospitalist leaders is “Make the data personal!” Start working on this today, so that within a few years, you, too, will have regular reports. Continue to aggregate quality data based on group performance and review it frequently. If you want more significant impact and greater physician engagement, make it personal. TH
Dr. Cawley is president of SHM.