I’m sure you are a good doctor, but how do you know? You might say—my patients come to see me and my appointment book is full, so that proves I’m good. But we know the truth of the matter is expressed in a formula I give to young doctors. For 5% of our patients, we are the only person who can take care of them, because their idiosyncrasies and ours line up perfectly. Another 5% will take an immediate dislike to us and the sooner they find someone else to be their doctor, the better off both of us will be. For the remaining 90%, they tolerate us as long as we are reasonably polite and reasonably kind, but almost anyone else could do what we do. So how do you know you are a good doctor?
The question has become more than an ego-building question in a time when the people who pay for medical care are questioning the value of what they receive from us. The usual way to do this is to use the methods of continuous quality improvement as originally popularized by Deming. (CQI—Wave of the Future.) The AHRQ maintains an excellent website that covers the nuts and bolts of how to do CQI in healthcare, as well as links to evidence base databases.
Here, I want to emphasize a couple of points that you need to keep in mind. First, most of the indicators available measure processes of care, but what patients care about are outcomes. Most of our process indicators bear little, if any, direct relationship to outcome. The choice of indicators may be mandated, as in the hospital core measures project, but if you get to choose, spend a lot of time and thought in defining your indicators. The better the processes you measure determine the clinical outcome, the more valuable the indicator becomes.
If you are going to use process measures of individual physician performance, you need to be aware of some other issues. You must choose the appropriate time interval for your measurement. Some measures should NOT be calculated every month, or even every quarter. You must be aware of the distinction between common cause and special cause variation. If you pick an appropriate measurement interval, you are more likely to be able to tell the difference, but, of course, it may take longer to do than you think reasonable. You must be aware of the problem of attribution. Rarely is a process under the direction of a single physician. Perhaps the appropriate level of attribution is the unit or team, rather than the individual. You must also be aware that statistical probability becomes stable only after 30 or more observations are in the data set. For most physicians, only a few problems will be sufficiently common that they will have 30 patients at risk in a given year. Lastly you must be aware of the misuses and abuses of CQI (Culture Matters).
Too often, I fear, CQI becomes divorced from decision-making in medical organizations. In 1999 I presented my notions about how using CQI for data-driven decision making can close the loop, improving both patient outcomes and nurse and physician satisfaction. (Building Resilient Dialysis Units). Fifteen years later, I remain convinced that wider application of these ideas is critical for medical organizations of all types as they navigate the changing waters of healthcare.
Medical Practice Articles
A Good Place To Work
Is your organization a just one? How do you know?
A Season for Everything
Maybe it is time to rediscover the art of medicine.
Medical organizations have a lot of data, much of which is not "actionable." However, if taken as a vital sign, such data can lead to important actions that indirectly improve "the numbers."
Activating Patients - The Achilles Heel of Healthcare Reform?
Studies show 25% of the population is not involved in their healthcare, but reform efforts assume wider application of evidence-based medicine is the key to better value. Perhaps it is the Achilles' Heel?
Alignment is another buzzword that means different things to different people.
Are We Too Task Oriented?
The number of tasks doctors must complete grows exponentially. Have we become too task oriented at the expense of our patients?
Attribution is a buzz word for deciding which individual provider is accountable for the cost of a patient's care. On paper the definition seems straight-forward, but in practice it is not really possible to define it.
Barriers to Innovation
Innovation is critical for organizational survival, but internal and external forces make it difficult.
Beyond Toxic Organizations
Are medical organizations toxic environments or is the problem one of changing generational expectations?
Big medicine may be financially necessary, but it poses risks unless care is taken to become a real system, which requires putting the clinical enterprise at the center.
Building Team Effectiveness
Buzz words are verbal shorthand phrases that often conceal complex underlying realities.
Care Redesign is one step needed to deal with clinician burnout.
Changing Physician Behavior
Clinical microsystems are composed of front-line clinicians engaged in direct patient care. Despite a lack of formal authority, they are the key to successful healthcare reform.
Coaching and Process Improvement
Can individual coaching be a key to process improvement?
Messaging is replacing dialogue in clinical practice to the detriment of all.
Confronting The Quality Paradox - Part 1
Confronting The Quality Paradox - Part 2
Accounting is not simply a matter of recording reality objectively, it makes things up and changes the definition of what really matters.
Confronting The Quality Paradox - Part 3
Confronting The Quality Paradox - Part 4
There will never be authentic quality within healthcare unless the word explicitly accommodates the truth that a human being is simultaneously both a subject and an object.
Confronting The Quality Paradox - Part 5
Costs and Wasteful Care
Thinking about aggregate cost won't help doctors reduce unnecessary testing, but understanding Bayesian analysis might.
Dunbar's research suggests a practical limit to our human capacity for emotional connection with others. This has important implications for dialysis unit function.
Is empathy the value we have tossed out as part of "improving" health care?
Engaging Burned Out Physicians
Fluid Intelligence Versus Crystallized Intelligence
Minimal staffing using employees with high "fluid intelligence" is a trend not yet proven to be effective. Maybe a better mental model is a combination of fluid and crystallized intelligence, not an "either-or" proposition.
Is the heroic age of medicine over? If not, what would heroism look like?
Improving Clinical Quality Under Fire
Touro Infirmary has been in the news but not in a good way. What should it do?
We are naturally drawn to the dramatic, heroic intervention, but real medical progress is measured in small increments.
Leading Through Teams
Meaning or Money
The question: is health care about money first or mission first?
Medical Care as a Commodity
Are big data and machine learning likely to solve the problem of uncertainty in medical practice?
Medical evidence is a four-source: guidelines, registries, data mining and " in my experience". Different clinical situations use different types of evidence and have different implications for provider behavior. These implications are considered in detail.
Everyone is opposed to wasteful medical spending, but we still don't have a robust definition of what is waste.
Money in Medicine
Money has always been part of medicine, but it seems both quantitatively and qualitatively different now.
Money and Medicine Part 2
Many physicians and hospitals have entered into employment relationships, but neither are happy with the result.
More on Biases
A recent series of articles in the New England Journal of Medicine provide more insight into the issue of bias in medical decision making.
More on Human Capital
Human capital is essential for any organizations, but failure to nurture it spells doom. Yet organizations routinely ignore this. Why?
More on Physician Work
The changing nature of physician work is decreasing the availability, and probably the quality of care at a time when demand is increasing. Two recent articles provide data supporting these effects.
More on Turnover from the Departing Staff Point of View
New Ideas About Electronic Health Records
The data entry burdens of electronic health records contribute to physician burnout and may harm patients. Two recent articles give hope that people are beginning to search for ways to turn EHR's into aids for patient care instead.
New Payment Methods
Nursing Staff Turnover
If empowered teams of clinicians is the key to effective, efficient care, then staff turnover is Achilles' heel. Nationally, RN turnover exceeds the cap needed to maintain patient safety and quality of care. The problem and approaches to a solution are considered.
On Dying in America
The IOM report "On Dying in America" makes recommendations for change that physicians should embrace.
Organizing for Success - Another Viewpoint
Organizing for Success - Key Requirement
A consideration of the interactions of patient preferences, evidence-based medicine and peer review.
An expert panel has concluded less than half of current measures used by CMS to assess value for primary care services are valid. What does this tell us about current pay-for-performance efforts?
Physician Decision Making
Physician decision-making is both complex and deals with uncertainty dooming current simple approaches to changing physician behavior.
It might seem obvious what a physician's work is, but there are conflicting definitions which are causing problems.
Politics and Medical Organizations
Organizational politics are inevitable, so recognizing the types and the advantages and disadvantages of each is important.
A new study suggests only 5% of Medicare spending in 2012 was preventable, much of it in frail, elderly patients. Is this good news or bad?
Putting Patients At The Center Of Healthcare
Putting patients at the center is crucial for healthcare organizations, but how can it be done?
Rationing is a dirty word, but a necessary part of healthcare reform. A consideration of the implication of this for practicing physicians.
Regret is a universal emotion. Although we try, avoiding regret is not possible, and our desire to do so creates costs to everyone.
Risk, Reward, and Other Reasons Patients Don't Follow Medical Advice
Patients often don't do what their doctors recommend. The problem is important and contributes to "bad" outcomes, yet we have little insight into the problem.
How do physicians deal with complex, uncertain health care situations? Scenario planning is better than quoting statistics.
Shared Decision Making
A consideration about decision making at the person, group and organizational levels.
Short Term Risk For Long Term Reward
Health care executives are faced with taking major short-term risks to their organization's survival in hopes of long-term benefit. This is new territory for them, but is a common problem for physicians.
Making simple ideas work turns out to be complicated and hard.
Wouldn't it be wonderful if we got rid of stupid stuff?
Building good teams is hard work. What does it take to be successful?
Team Building II
Team building is hard work--getting the right people and bring them in right are important processes.
Team Building III
Addressing why teams are formed requires considering mental models, transactive memory, and team learning.
Team Building IV
Since people aren't like Mr. Spock, team building must consider emotional factors to be successful.
Team Building V
Successful medical organizations are intentional about developing and maintaining robust small unit leadership.
The 1% Solution
Efforts to constrain health care costs have not been very effective. Maybe instead of grand solutions we need a series of "1% solutions."
The Anchoring Heuristic
Businessmen and health policy experts fail to recognize the limits imposed by the experiential nature of medical practice, both of which impact achieving the "triple aim."
The Center Effect
Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect. This has important implications for hospitals and health care organizations as they respond to public reporting of data.
The Hospitalist Dilemma
Is the hospital medicine model a boon, a bane, or a response to an unresolved underlying problem?
The Primary Care Dilemma
When people are well they want convenient care, but when they are sick they want "the best." Is that possible?
The Limits of the Medical Model
The Practicing Physician and Medicare
Healthcare institutions have unintentionally become toxic places to work. What can be done to address this?
Turnover From the Perspective of the Departing
Dealing with uncertainty is at the core of practicing medicine. Have we tried to escape this reality?
Unit Culture and the Leader
Creating and maintaining a positive, patient-oriented culture that supports doing the right thing the right way is the central task of medical leadership today.
Waste and the Cost of Care
There is no doubt individual health care expenditures have grown faster than the economy. Is this due to increased intensity of service (waste)?
What Business Are We In?
All healthcare organizations have both a clinical and a business function. The proper balance is crucial for success.
What Do I Owe?
A discussion of unexamined assumptions about what physicians owe their hospitals.
What Makes a Successful Physician?
What skills are required to be a successful practicing physician?
What really matters to practicing physicians?