Have Patience
Administrators rightly want solutions yesterday. But clinical transformation of this type takes time. We will not unfurl the “Mission Accomplished” banner in three months. This will take years, probably a decade. For two reasons:
- This requires culture change, which takes time.
- We need bench strength.
A focus on quality cannot be accomplished with five or even 50 people working on this. Rather, it requires 500 to 5,000 people—indeed, the entire organization. It takes time to change the culture, engage the people, and make the mistakes that success requires.
Make It Easier To Do The Right Thing
We have to remove the barriers that limit success. This means not asking high-paid physicians to do chart abstraction, analyze data, and coordinate meetings—support staff should perform these tasks.
We also need institution- and provider-level data. Without valid and timely provider-level data, it is exceptionally difficult to create the needed sense of urgency for change. Show me I’m not meeting my expectations, and I’ll do what it takes to change. Leave me to believe that I’m the best doctor in the world—as we all are, of course—and I have no impetus to improve.
Success requires the infrastructure that makes it harder to do the wrong thing and easier to do the right thing.
Show Me The Money
Quality cannot be an unfunded mandate. Infrastructure needs to be built, support staff hired, and physician time protected to devote to this work.
That being said, I’d submit that if after five years an institution doesn’t see a return on investment (in cost avoidance and increased revenue) of at least 5:1 for every dollar spent, then either you’ve built it wrong or we are all misreading the tea leaves in terms of value-based purchasing. I wouldn’t bet on the latter.
Partner With Your Partners
Medicine is a team sport. True success hinges on a multiprofessional approach. Our success will be directly proportional to the degree to which we engage our clinical-care partners.
This is a less autonomous way of thinking than most of us were taught. We studied alone, took tests alone, saw patients alone. To engage nurses, therapists, pharmacists, and hospital administrators in a dynamic team is outside most of our comfort zones.
Culturing Change
We cannot mend our broken system until we begin to do things differently. Success demands that we work in teams, partner with our hospital administrators, and agree to be measured. We must better communicate with other providers, reduce variability, forgo some autonomy, and shift from physician- to patient-centric care models. This will be hard. This will be uncomfortable. This will require tough decisions.
Failure or Success
Which brings me back to our task force’s definitional divide. The issue was how strongly we push physician involvement in our quality and safety program. Do we encourage all doctors to participate (doctors “should”), or do we require all doctors to participate (doctors “must”)? The task force was divided.
On the one hand, it’s hard to mandate involvement. This would be a huge physician commitment. It would take a lot of training, time, effort, and money. There would be innumerable challenges, perhaps physician turnover.
Was this a battle worth fighting? The difference between “should” and “must” is quite small. They say nearly the same thing. Except they don’t. “Should” says it’s optional; “must” is a mandate. “Should” says it’d be nice if you’d do this; “must” states it’s an institutional priority.
This distinction is not small. It is the difference between indifference and commitment, between our present and our future, between failure and success.