Becker's Hospital Review

54 CARE DELIVERY right away. is provides a safe and constructive environment for departments to talk about what behaviors drive better results. It also facilitates discussion about effective clinical pathways, so physicians can walk away with a resolve to improve standardiza- tion, Mr. Belokrinitsky says. e next meetings should be individual. Hospital leadership should meet with low performers and show them their results, giving physicians a chance to explain their outcomes. is con- versation will be much easier if it's built about cost rather than quality. "Quality is very touchy," Mr. Belokrinitsky says. "It calls into question how good of a physician you are." Choose metrics wisely Some say setting the bar for performance leads physicians to avoid a complex case load. To hit their benchmarks, physicians may cherry pick the most textbook cases and leave the unique cases to the rest. Lisa Rosenbaum, MD, details one such instance in an op-ed published by NEMJ: "One Monday morning, rounding on a patient who need- ed relatively urgent coronary-artery bypass surgery, a newly ap- pointed cardiologist in New York asked the team to call a sur- gical consult (some details have been changed to protect those involved). 'We can't call today,' the cardiology fellow explained patiently. 'Dr. X. is taking consults. He wouldn't touch our patient with a 10-foot pole.' e fellow scrutinized the call schedule. 'e only surgeon who might take him isn't on until Wednesday,'" Dr. Rosenbaum wrote. Her article was a reaction to the Surgeon Scorecard, which she felt was an unfair evaluation of quality. She wrote specifical- ly on New York since it was one of few states to publicly report cardiac surgery and percutaneous coronary intervention, which motivated the cardiologist in question to avoid complex cases. is phenomenon — similar to what Mr. Belokrinitsky calls "turfing," or protecting one's turf by moving complicated cases to different hospital units — is preventable. "To avoid those behaviors, before you engage with physicians, you have to think as an administrator about what the few quality metrics are that matter to you," Mr. Belokrinitsky says. Adminis- trators must choose metrics and benchmarks most meaningful to patient care and help practitioners understand why they were chosen. End the excuse As hospitals begin to reward value over volume, physicians are becoming more comfortable with metrics and benchmarking, and less apt to say, "My patients are sicker." "ese days I am hearing less and less of this reasoning from physicians compared to five to seven years ago. is could be partly due to the fact that physicians are getting familiar with data reporting in their practices from third party payers," Dr. Gopi- nath says. Nonetheless, it's likely not the last time a provider will at- tempt to explain away poor outcomes or poke holes in perfor- mance data. Hospital leadership must work with physicians to ensure data is as clean as possible, and when it is, help providers learn from it. As Dr. Gopinath puts it, today's mantra in healthcare is "transparency." e increasing popularity of physician data from sources like Physician Compare, Yelp, the Surgeon Scorecard and even hospitals' own sites indicate performance data is here to stay. "I encourage physicians to adapt to the changing landscape in healthcare and quality reporting, rather than resist it," he says. n What This Physician Thinks is Wrong With Quality Benchmarking By Emily Rappleye M any physicians are now evalu- ated based on the health out- comes of their patients, or at least the numerical data that is closest to approximating the health outcomes of their patients. This may translate to surgical complications, diabetes man- agement or vaccination or medication compliance. For Abigail Zuger, MD, an internist and infectious disease specialist, her benchmark for continuous quality im- provement is the HIV viral load. As Dr. Zuger confessed in a recent blog for The New York Times, her grades show she is a "B" student, which for anyone who has the drive to get through med- ical school is a less-than-satisfactory grade. Dr. Zuger attributes her failures to a patient whose viral load has dropped from several million to 11,000, despite his distrust of the medical system. She attributes it to another patient who stopped receiving his medications due to issues with his prescription insur- ance. After missing months of treat- ment, his viral load was 100,000. He went back on medication and earned Dr. Zuger a failing grade. However, she writes, those patients are successes in her book. Like anyone with a less-than-satis- factory report card, Dr. Zuger has a host of excuses, or reasons and narratives for her results. She writes, "You could say it's all so much embroidery. Or you could say that the numbers don't tell the whole story." n

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