Quality, Physician Culture - - Health Care Poker

Health Care Poker

Poker is a card game in which players attempt to acquire a winning combination of cards that involves betting at every deal. In today’s health care reform, many consider autonomous physicians as the wild card in a deck generally stacked in favor of big government, big insurers, and big health care organizations. .

It is independent physicians, policy makers, health care executives, and reformers lament and complain, who,

• still have freedom to prescribe drugs, order tests, do procedures, and hospitalize patients, willy-nilly, as they please.

• still lack wisdom to invest in and install EMRs, refuse to abandon solo medicine, and continue to act on clinical instinct rather than on “evidence-based” protocols, perform “unnecessary” tests and operations, respond to fee-for-service incentives to do more, succumb to blandishments of device and drug manufacturers, and yield to patient pressures for the best and the latest. .

The argument seems to be: This is a free country, but quality and clinical judgments are too important to be left to independent physicians exercising their own judgment and acting on their own.

I satirized these different views in a tongue-in-cheek July 30 blog “Interview with a Health Care Buzz Word Expert.” The responses were not long in coming. Doctors greeted the blog with bemusement and amusement . Consultants were not so kind.

One consultant, Scott Hodson, formerly a Deloitte consultant who now owns his own firm to help health care organizations found my blog off point.

Here, in part, are his comments.

“Very creative and entertaining! However, I think that providers bear the brunt of the responsibility to improve the quality, efficiency and affordability of health care.

Many American health systems are significantly underinvested in quality management Infrastructure, Process, and Organization. To achieve breakthrough improvements in quality, patient safety, and resource utilization/cost of care, hospitals and physicians must work together to develop a "world class" quality management foundation that includes:

Strategy: including a clear linkage of quality and patient safety to the organizational strategy and a Board-driven imperative to achieve quality goals.

Infrastructure: incorporating effective quality management technology, EMR and physician order entry, evidence based care development tools and methodologies, and quality performance metrics and monitoring technology that enables "real time" information.

Process: including concurrent intervention, the ability to identify key quality performance "gaps," and performance improvement tools and methodologies to effectively eliminate quality issues.

Organization: providing sufficient number and quality of human resources to deliver quality planning and management leadership, adequate informatics management, effective evidence based care and physician order set development, performance improvement activity, and accredition planning to stay "survey ready every day."

Culture: where a passion for quality and patient safety is embedded throughout the delivery system and leaders are incented to achieve aggressive quality improvement goals.

My firm has assisted a number of progressive health systems to achieve such a foundation, and to develop truly World Class Quality.”

I do not quibble with his remarks, which represent the organizational point of view. But as the August 3 “Bright Idea” section in the New York Times, notes, “small is the new big.” Health care organizations are learning the charms – and innovative side effects, - of thinking small at the physician level. . Innovations are just as likely to come from the bottom-up, physicians seeking freedom, personal satisfaction, and fulfillment, as from “progressive organization” leaders seeking control from the top down. In health care poker, physicians may hold the bottom hole card.