By Marie de Martinez, M.A., FACHE and A. Kathy Morse, R.N., M.D., FACP, SAGE Healthcare Collaborative, Inc.
Collaborative hospital–physician relationships and board quality committees are the new financial performance drivers. When physician–hospital relationships are the responsibility and focus of the board and executive leadership, culture and quality thrive and financial performance improves as a by-product.
Physician–Hospital Relationships and Orientation: Organizational Culture and Performance Expectations
Physician employment, joint ventures, and integrated delivery systems of all varieties are now imperatives for all hospitals hoping to do business with the federal government. Too often, hospitals and physicians agree on an employment plan or business venture, sign the papers, and they’re off, without the slightest (if any) attention paid to understanding and integrating into the hospital culture and vice versa.
Historically, hospital employees were required to participate in a one-to-two day seminar that detailed organizational structure, patient services lines, infection precautions, locating emergency exits, patient care in emergency situations, etc., as well as hospital/health system culture. In efforts to become more efficient—and be more easily accessible to employees—the process has evolved. Much of it is now completed online. This approach leaves little room for discussion and can hinder the employees opportunity to deepen their understanding of the organization.
In a separate physician orientation, physicians may learn how to work through e-signatures, to access and complete patient care documentation, and receive a map of the facilities. But except for initial statements, which require agreement to proceed with the application for employment, very little time is spent discussing and ensuring an understanding of the hospital or health system culture and appropriate behavior. Physicians are expected to begin the work of medical care and healing in an environment they don’t understand, with expectations they learn on a need-to-know basis, more or less. These new employees are often newly minted physicians who do not know how to navigate the healthcare system of which they are now considered a leader. They rarely understand professional communication processes other than what they have experienced in the academic medical center, and during student, resident, and fellowship rotations.
In order to ensure an understanding of the culture and performance expectations, employed physicians should be offered a mentor who can guide them through clinical and management issues. This process is usually created and led by executive leadership, and they help ensure accountability for reporting and follow-up. The board needs to be aware of the process and receive progress reports regarding how it has impacted patient care. Mentors need to be familiar with the new physicians’ medical specialty, and be able to guide them in physician-to-physician communication, clinical team collaboration, and patient care quality goals they are expected to achieve. Information should be provided that details performance expectations, as relates specifically to their progress on a predictable timetable. Quarterly performance review with their supervisor, with input from the clinical mentor, would be ideal as a first step. This is the forum for formal feedback and course correction. Daily feedback should be constructive and supportive, and offered by the clinical mentor and the patient care team. The quicker missteps are corrected, the less likely they will become part of the physicians’ repertoire.
Assuming the physician is equipped with medical skills, willing to assume their position within the hospital/health system culture, and they understand expectations, then they are equipped to take the lead in quality patient care goals.
Anecdotally, it is our experience, that physicians—especially hospitalists—are not held accountable to their own contracts. Without requiring performance by employed and community physicians, hospitals will never achieve lofty goals, and patients will not benefit from continually improved care.
Board Quality Management Initiative
Beginning in 2012 all hospitals lose 1 percent of their Medicare reimbursement to subsidize incentives earned by hospitals that perform well on key quality measures. Hospitals that have developed a quality committee, or a similar board committee, will probably perform better than boards without such a subcommittee.[1][2]
Unfortunately, some hospitals don’t have a quality committee, and, more often than not, if the board does have a quality committee, it only reviews information pertinent to core measures. To truly manage ultimate financial results of care, the entire board should understand some of the global quality measures beyond just those required by CMS (core measures). Begin this board education process by explaining the difference between core measures and outcomes and how outcomes can be monitored. Examples of outcomes that may be appropriate to monitor include time to the operating room for hip fracture patients, (with a goal of less than 48 hours); 30-day all-cause readmission rates and mortality rates for patients with pneumonia, heart failure, and acute myocardial infarction; and appropriate use of palliative care referrals. The board needs to be aware of results that are posted on the CMS Hospital Compare Web site, and the soon to be active Physician Compare Web site, which will look at quality indicators for individual physicians.[3] These are free Web sites that allow the public to compare up to three hospitals or physicians in various metrics.
Key factors determining whether or not hospitals will earn incentives for best practice performance are basic to both hospital administration and to clinical practice. These factors include the strength of the physician–hospital relationship and the institutional commitment to flawless care, as evidenced by performance information provided transparently to those with the most influence (physicians and the patient care team) in achieving it. A board quality committee that commands as much attention as the finance committee will be a true indicator that commitment is unwavering.
For hospitals with strong relationships with their clinical staff, rooted in a mutual dedication to evidence-based patient care, incentive payments will be a welcomed reward and further motivation to continue their work. CMS designed the incentives to highlight and extend best practices across the country, and to reduce tolerance for fragmented care.
Examples
One of the indicators most important to CMS is the rate of hospital readmissions within 30 days following an acute care inpatient episode. Excess readmissions (over 18.6 percent in 30-day all-cause readmissions) for certain diseases such as pneumonia, acute myocardial infarction (AMI), and heart failure have been examined. From CMS’s perspective, this is due to the potentially disastrous health implications for the patient and resultant financial trauma to the payer.
The challenge in this case is that a hospital may not know which patients are being readmitted to facilities other than its own. The solution is to design and continually improve processes based on best practices. This leads to care that accounts for changes in patients’ health status, addresses issues, then resumes with the proven processes. We do not suggest that processes be followed laboriously at the expense of common sense, but that they be used as proven guides to the destination of improved health, without additional or protracted health threats to the patient.
In order to manage such a complicated series of actions with all their potential variables, the hospital must understand its true all-cause readmission rate, and take action. Address what is causing those patients to be readmitted by documenting and redesigning actions and steps along the way for all patients who fall within that disease category.
Actions that have proven successful at preventing readmissions have involved the hospital–physician leadership moving care outside hospital walls. An example of a successful process to reduce readmissions is the outpatient heart failure clinic.[4][5] While this is not a financial giant in and of itself, in many cases, it eliminates patients returning to the hospital within 30 days of their admission for what becomes essentially unfunded care. These clinics have the added advantage of improving patient satisfaction and compliance. Of those services, which may be comforting to the patient and especially the family, telemonitoring—usually through home health care—has not seen the success in preventing readmissions that, on face value, it would promise.[6] Home health is not necessarily the answer because service providers aren’t specialists in heart failure.
For surgical patients, the concept of standardized pre-operative care (two to four weeks pre-operative) with the identification of patients at high risk for certain post-operative complications is becoming the norm.[7] [8] Once these risks are identified, there are triggers in pre-operative, operative, and post-operative areas to change care to reduce complications post-operatively. These changes will usually reduce length of stay and improve patient outcomes. This may become even more important in light of bundled payments and as integrated systems become more prevalent.
Everything to Gain
Next year’s CMS incentives are a prelude. Starting in FY 2013, hospitals with excess readmissions will see a 1 percent reduction in payment for all Medicare discharges. This will increase to 2 percent and 3 percent in subsequent years. This will further reward hospitals with strong hospital–physician clinical collaborations guided by thoughtful, informed boards and will penalize those with poor performance. Hospitals with cultures grounded in focused patient care will realize financial gain as a by-product of quality patient care.
Most assuredly, hospitals can achieve success in patient care and physician satisfaction by communicating what is important and why it is important. Setting standards for patient care with physicians, who are best able to influence patient outcomes, demonstrates a commitment to collaboration and recognizes physicians as clinical leaders. Orienting new physicians by sharing goals, progress made toward achieving them, and clear delineation as to each physician’s expected contribution in goal attainment will serve to strengthen the hospital–physician relationship. Clear, meaningful communication concerning quality goals and everyone’s role in achieving them will ensure they are reached. The more incentives the hospital will be paid, the more engaged the physician will become, the more likely the physician will stay in the community, and on and on. Physician–hospital relationships centered on quality patient outcomes will lead to more satisfied patients and higher volumes, and the right care in the right setting.
The Governance Institute thanks Marie de Martinez, M.A., FACHE and A. Kathy Morse, R.N., M.D., FACP from SAGE Healthcare Collaborative, Inc. for contributing this article.
[1]“Preventing Unnecessary Readmissions: Transcending the Hospital’s Four Walls to Achieve Collaborative Care Coordination,” The Advisory Board Company, 2010.
[2]Richard F. Averill et al., Redesigning the Medicare Inpatient PPS to Reduce Payments to Hospitals with High Readmission Rates, Health Care Financing Review, Vol. 30, No. 4 (Summer 2009): 1–15.
[3]Visit the Hospital Compare Web site at www.hospitalcompare.hhs.gov. CMS will launch the Physician Compare Web site in January 2013.
[4]Stephen Bird et al., “An Integrated Care Facilitation Model Improves Quality of Life and Reduces Use of Hospital Resources by Patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure,” Australian Journal of Primary Health, Vol. 16, No. 4 (2010): 326–333.
[5]Brett D. Stauffer et al., “Effectiveness and Cost of a Transitional Care Program for Heart Failure: A Prospective Study with Concurrent Controls,” Archives of Internal Medicine, Vol. 171, No. 14 (2011): 1238–1243.
[6]Fredrich Koehler et al., “Impact of Remote Telemedical Management on Mortality and Hospitalizations in Ambulatory Patients with Chronic Heart Failure,” The Telemedical Intervention Monitoring in Heart Failure Study, Circulation, Vol. 123 (2011): 1873–1880.
[7]Angela Bader and David L. Hepner, “The Role of the Preoperative Clinic in Perioperative Risk Reduction,” International Anesthesiology Clinics, Vol. 47, No. 4 (2009): 151–160.
[8]Darin J. Correll et al., “Value of Preoperative Clinic Visits in Identifying Issues with Potential Impact on Operating Room Efficiency,” Anesthesiology,Vol.105, No. 6 (December 2006): 1254–1259.