IMPROVING PHYSICIAN IMPROVING PHYSICIAN DECISIONSDECISIONS

CHAPTER 32CHAPTER 32

Code Blue Health Science Edition 4Code Blue Health Science Edition 4

Quality ControlQuality Control

Although Wes has spent significant Although Wes has spent significant time trying to solve the financial time trying to solve the financial problems of the hospital, the new problems of the hospital, the new administrator also recognizes the administrator also recognizes the importance of correcting problems importance of correcting problems in the quality of healthcare offered in the quality of healthcare offered by his facility.by his facility.

Outcomes ManagementOutcomes Management

• Quality control has not always Quality control has not always been a top priority of healthcare been a top priority of healthcare providers.providers.

• The reluctance to address the The reluctance to address the quality of care given by individual quality of care given by individual doctors on the medical staff can be doctors on the medical staff can be illustrated by the history of illustrated by the history of outcomes managementoutcomes management..

Outcomes ManagementOutcomes Management

• Outcomes management focuses on Outcomes management focuses on measurable improvements in measurable improvements in patient health due to specific patient health due to specific procedures or treatments.procedures or treatments.

History of Outcomes History of Outcomes ManagementManagement

• The approach was first proposed in The approach was first proposed in 1913 by a Harvard surgeon named 1913 by a Harvard surgeon named Emory Codman.Emory Codman.

• He called it the He called it the end results idea.end results idea.• It consisted of tracking surgical It consisted of tracking surgical

patients for a year to see how their patients for a year to see how their treatment turned out.treatment turned out.

Early surgical center

History of Outcomes History of Outcomes ManagementManagement

• The goal of tracking surgical The goal of tracking surgical procedures was to discover their procedures was to discover their most likely cause of success or most likely cause of success or failure.failure.

• Codman planned to collect Codman planned to collect information into a database to information into a database to improve treatment profiles.improve treatment profiles.

History of Outcomes History of Outcomes ManagementManagement

• Unfortunately, his proposal to the Unfortunately, his proposal to the American Medical Association was American Medical Association was essentially ignored – it got only essentially ignored – it got only $500 in funding.$500 in funding.

• More important to Codman, other More important to Codman, other doctors stopped sending patients doctors stopped sending patients to him, his practice suffered and to him, his practice suffered and he abandoned the idea.he abandoned the idea.

History of Outcomes History of Outcomes ManagementManagement

• In 1919, the concept was In 1919, the concept was resurrected by the American resurrected by the American College of surgeons to perform a College of surgeons to perform a study of 692 hospitals with 100 study of 692 hospitals with 100 beds or more.beds or more.

• The study showed that only 89 met The study showed that only 89 met minimum standards.minimum standards.

History of Outcomes History of Outcomes ManagementManagement

• The response of the Board of The response of the Board of Regents to the report was swift Regents to the report was swift and uncompromising.and uncompromising.

• They collected all the copies, They collected all the copies, carried them to the basement of carried them to the basement of the hotel and burned them.the hotel and burned them.

Outcomes ManagementOutcomes Management

• Despite its rocky start, outcomes Despite its rocky start, outcomes management is receiving attention management is receiving attention again because of pressures from again because of pressures from employers and consumers employers and consumers concerned with healthcare quality.concerned with healthcare quality.

Outcomes ManagementOutcomes Management

• One approach to outcomes One approach to outcomes management is to build clinical management is to build clinical pathways, doctor guidelines, and pathways, doctor guidelines, and treatment protocols.treatment protocols.

Clinical PathwaysClinical Pathways

• A clinical pathway is a guide for physicians A clinical pathway is a guide for physicians and nurses.and nurses.

• It is designed to provide decision paths to It is designed to provide decision paths to be followed in diagnosing and treating be followed in diagnosing and treating patients.patients.

• The goal is to standardize the practice of The goal is to standardize the practice of care so the providers use only those care so the providers use only those diagnostic and treatment options diagnostic and treatment options scientifically shown to provide the best scientifically shown to provide the best medical outcomes.medical outcomes.

Treatment ProtocolsTreatment Protocols

• A treatment protocol is a A treatment protocol is a procedure that should be followed procedure that should be followed under specific conditions.under specific conditions.

Medical Practice Medical Practice Non-uniformityNon-uniformity

• Research conducted by several Research conducted by several medical schools shows there is a medical schools shows there is a large geographical variation in large geographical variation in treatment patterns among doctors. treatment patterns among doctors.

• Patients like to think their doctors’ Patients like to think their doctors’ approach is based on research, but approach is based on research, but unfortunately that’s not always unfortunately that’s not always true.true.

Journal of Strategic Journal of Strategic Performance Performance MeasurementMeasurement

• ““Most practices in clinical medicine have never Most practices in clinical medicine have never been tested in double-blind peer reviewed been tested in double-blind peer reviewed scientific studies, or even thoroughly for scientific studies, or even thoroughly for prospective statistical analysis. When practice prospective statistical analysis. When practice techniques have been firmly established or techniques have been firmly established or debunked in such studies, the knowledge often debunked in such studies, the knowledge often does not affect clinical practice. Many doctors fail does not affect clinical practice. Many doctors fail to hear of the new knowledge, others routinely to hear of the new knowledge, others routinely ignore it, preferring to continue to practice the ignore it, preferring to continue to practice the way they were taught in medical school.”way they were taught in medical school.”Flower, Joe. “Measuring Health,” Flower, Joe. “Measuring Health,” The Journal of Strategic Performance The Journal of Strategic Performance MeasurementMeasurement, August/September 1998, Volume 2, Number 4., August/September 1998, Volume 2, Number 4.

Why don’t doctors always follow Why don’t doctors always follow the best practice patterns?the best practice patterns?

• Some physicians don’t know what the Some physicians don’t know what the best approaches are.best approaches are.• The best solution for this is education.The best solution for this is education.

• Some physicians get bogged down in Some physicians get bogged down in dealing with the large volume of dealing with the large volume of information needed to make information needed to make decisions.decisions.• One tool to assist in solving this is One tool to assist in solving this is

decision-tree software.decision-tree software.

What can hospitals do What can hospitals do to improve physician to improve physician

decisions?decisions?• In-service educationIn-service education• Adoption of practice protocols that Adoption of practice protocols that

are shown to have the best are shown to have the best outcomesoutcomes

• Use boundary guidelines that Use boundary guidelines that define medical practices beyond define medical practices beyond which doctors incur penaltieswhich doctors incur penalties

The EndThe End