Hospital Strategies to Engage Physicians in Quality Improvement

Issue Brief No. 127

October 2009

Allison Liebhaber, Debra A. Draper, Genna R. Cohen

Over the past decade, mounting evidence that the quality of U.S. health care is inconsistent at best has driven increased attention to quality improvement, particularly within hospitals. Although physicians are essential to hospital quality improvement efforts, getting them to focus on these activities is difficult because of competing demands on their time and reimbursement pressures. To overcome these obstacles, hospitals must deploy a range of strategies, according to a Center for Studying Health System Change (HSC) study of four communities -- Detroit, Memphis, Minneapolis-St. Paul, and Seattle. These strategies include employing physicians directly; using credible data to pinpoint areas needing improvement; providing visible support from hospital leadership; identifying and cultivating physician champions to help engage their peers; and communicating the significance of physicians' contributions. While hospitals are achieving gains in patient care quality, substantially more progress could likely be made through stronger alignment between hospitals and physicians working collaboratively on quality improvement.

Physician Involvement Key to Hospital Quality Improvement

In recent years, reports such as the Institute of Medicine's Crossing the Quality Chasm have brought care quality issues to the forefront. The disconnect between costs and outcomes has further elevated awareness of the need to improve health care quality, including in the nation's hospitals. The United States spends roughly $2.4 trillion annually on health care -- nearly one-third of which goes to hospital care. Yet, American health outcomes are comparatively worse than those in many other developed countries that spend less.

Although hospitals have long conducted quality improvement (QI) activities, they continue to face growing demands to participate in a wide array of quality improvement and reporting programs. Furthermore, hospitals' financial and reputational interests increasingly depend on demonstrating high quality and improving when shortcomings are found. The Joint Commission, for example, requires hospitals seeking accreditation -- which is often necessary for payer reimbursement -- to show compliance with the National Patient Safety Goals, a set of standards focused on reducing hospital-acquired infections and other patient safety concerns. Additionally, the Centers for Medicare and Medicaid Services (CMS) collects data on a core set of quality measures from hospitals through its Reporting Hospital Quality Data for Annual Payment Update program. Hospitals that do not participate or fail to meet CMS reporting requirements receive a 2-percentage-point reduction in their annual payment update. More recently, CMS also began withholding payment to hospitals for so-called never events -- medical errors such as foreign bodies left in surgical patients and preventable post-operative deaths.

Given the mounting pressure on hospitals to raise patient care quality, engaging physicians in hospital QI initiatives is critical. Physicians are the primary decision makers regarding a hospitalized patient's care and are integral to QI projects, from improving hand-washing compliance to reducing ventilator-associated pneumonia. Yet, hospitals' efforts to engage physicians in improving patient care come at a time when physicians face growing reimbursement and time pressures. Hospitals are using a variety of strategies to overcome these challenges and secure physician involvement in QI, according to an HSC study examining physician participation in hospital QI activities in four communities: Detroit, Memphis, Minneapolis-St. Paul, and Seattle. These strategies include: employing physicians; using credible data to encourage their involvement; demonstrating visible commitment to quality through hospital leadership; identifying and cultivating physician champions; and communicating the importance of physicians' contributions.

Employment Engages Physicians

While there is broad recognition that physician involvement is essential for hospital QI initiatives, hospitals face a major challenge in securing physicians' time. Even relatively straightforward activities associated with quality improvement, such as attending meetings or reviewing proposed changes to hospital processes, are difficult for a physician with a heavy patient load. As one physician respondent lamented, "These activities are enormously time consuming... and your patient responsibilities never go away." Nearly all respondents acknowledged that the trade-offs for physicians -- sacrificing either personal or billable time -- are hard to resolve.

Many hospitals have historically depended on the voluntary medical staff model to solicit physician participation -- a model generally premised on a loose connection between hospitals and community-based physicians. However, as more services shift to outpatient settings and physicians confront quality-of-life issues and financial pressures, physicians increasingly feel less obligated to volunteer for functions such as serving on hospital committees in return for hospital privileges. Engaging loosely affiliated physicians in hospital QI projects can therefore be particularly challenging due to competing priorities. While respondents frequently described medical staff bylaws as encouraging physicians to "be good citizens" and participate in QI activities, the bylaws often lack the specificity or accountability mechanisms to clearly define physicians' responsibilities.

Hospitals are increasingly employing physicians, often as part of a broader alignment strategy that includes securing emergency call coverage and launching new service lines to attract more patients. For physicians, employment can be attractive because it eliminates the administrative burden of running a private practice, provides a predictable income, offers relief from high malpractice premiums, and allows for a better work-life balance. Quality improvement is typically not the primary motivation for tighter hospital-physician alignment, but employment can create incentives for physician involvement in QI, as one chief medical officer (CMO) described by "achieving economic alignment around the shared quality agenda." To ensure alignment, hospital executives reported more frequent use of formal job descriptions and contractual arrangements that specify physician responsibilities related to QI participation and increased accountability for results.

Employing physicians can reduce the competing pressures on their time to participate in QI activities. Other advantages include greater physician accessibility and visibility, as well as a ready pool of potential champions to help galvanize support and engagement among their peers. However, respondents frequently cautioned that employment by itself is not enough to gain and sustain physician involvement without other supporting factors, including credible data to motivate engagement, personal interest, and additional encouragement from the hospital.

Credible Data Motivates Improvement

Reliable data to identify areas requiring improvement and systematically track progress are essential for securing physician participation in hospital quality improvement. As one hospital chief executive officer (CEO) put it, "People rally around data, around measurement, and around evidence-based practice." Many respondents recounted how physicians tend to assume they are providing good quality care until they are shown data that demonstrates otherwise. For example, at one hospital, physicians had lower hand-washing rates than other caregivers. Only when the data were broken down by caregiver type could physicians see they were less compliant and begin to focus on improvement.

Although hospitals' participation in CMS, Joint Commission, and other programs has driven increased data collection, many hospitals still report being "starving" for good data. Many data sources are retrospective and administrative in nature (e.g., billing data), which makes physicians skeptical. Hospitals are trying to use other sources, such as chart reviews, which are expensive. As a national hospital association representative stated, "We are not lacking for data; we're lacking for useful information to guide decisions. You can undermine your credibility by giving physicians data that are not reliable, not representative, or not useful."

Using external, risk-adjusted data is one way to enhance data credibility. Several respondents cited the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) as a particularly valuable data source for surgical specialties. Benchmarking against other institutions is also important. Academic medical centers placed high value on comparing their performance with other University HealthSystem Consortium hospitals, and children's hospitals reported great benefit from benchmarking against other Child Health Corporation of America hospitals.

Although still evolving, some hospitals are moving toward using benchmarked data, when available, to provide physicians with feedback about their performance relative to their peers, either within the hospital or in comparable care settings. Some hospitals give physicians individual-level data, while others distribute aggregated quality scorecards. Hospital executives reported that this type of feedback appeals to physicians' competitive nature. As one hospital director of quality improvement noted, "Helping them understand goals and then providing them with data on how they're performing against those goals on an individual basis compared to their peers is another proven strategy for driving engagement."

Providing physicians with data support for QI -- staff to collect and analyze information -- is also critical. This is typically accomplished by assigning hospital staff to serve as project managers for physician-led QI projects. Hospital executives highlighted the positive impact of quality departments assuming greater ownership of data collection and making it readily available to physicians so they do not have to devote their limited time to assembling information.

The impact of information technology (IT) on quality improvement is "a mixed bag." Respondents acknowledged that IT has provided access to more timely, better-organized information, allowing hospitals to improve reporting of individual physician and department performance. IT has also enhanced hospitals' ability to communicate with physicians by posting QI-related messages or performance results on websites or physician portals. In some ways, however, IT has also reportedly made obtaining information more complex. Common complaints included the lack of interoperability or consistency across inpatient and outpatient settings and across different hospital campuses, meaning that gathering comprehensive data remains cumbersome. Many hospital executives reported they were in the early stages of implementing electronic medical record (EMR) systems and had not yet reached the point where they could fully leverage these tools for QI.

Committed Hospital Leadership Engenders Physician Support

Visible commitment from hospital leadership can foster physician involvement in quality improvement activities. For example, several respondents noted how helpful it was when hospital boards took an active role in the QI agenda. As one respondent observed, "We're seeing growing interest at the board level in hospitals around quality... that connection between the board and medical staff seems to be an area with strong potential for support. If the board is supportive of quality efforts and is more engaged, that sets the tone."

A key role of hospital leadership is building a strong quality culture by publicly demonstrating that QI is important, supported, and encouraged. Respondents from several hospitals noted that leadership turnover often led to shifts in QI priorities and methods, but hospitals with a well-established QI culture were better able to keep physicians engaged despite the changes. As one hospital chief nursing officer (CNO) described, it's an environment where "you get on the boat or the boat leaves without you." This is reportedly achieved by providing clarity about QI expectations, building appropriate infrastructure, and institutionalizing that direction across the organization.

Respondents praised senior leaders who go onto patient floors to talk with patients and staff and see quality challenges firsthand. Some noted how valuable it was for senior leadership to accompany physicians on patient care rounds, enabling some quality discussions to take place in real time.

QI also requires adequate resources, which is challenging for hospitals as quality improvement demands continue to escalate. As one CMO noted, "If physicians are going to engage in quality projects, they want to be sure the hospital is going to back them up. Once they've completed a project they need to know the hospital has the will to maintain the gains." However, several respondents noted that after implementing initiatives mandated by external organizations, they were often left with limited, if any, resources to pursue other activities of interest to hospital staff.

Physician Champions Foster Broader Participation

Physician involvement in hospital QI is reportedly often concentrated among a small fraction of the active medical staff. While respondents were generally positive when describing these physicians' efforts, they were frustrated that it was "always the same people." Finding ways to engage more physicians is essential to QI, which ultimately requires all medical staff members to adopt process and practice changes. Respondents cautioned that continued reliance on the same group of individuals can lead to burnout and also restrict the number of QI activities that can realistically be undertaken.

Hospitals frequently look to physician champions to advance their quality agendas and elicit broader physician participation. Respondents stressed the importance of physician champions being highly regarded in their clinical specialty. Most also noted that physicians who emerge as champions tend to possess certain personality traits, such as a willingness to challenge established practices, the ability to command attention, and a talent for inspiring passion in others. As one CEO described a physician champion at his hospital, "Every thought process he has runs through a filter of 'what impact will this have on quality?'"

To nurture physician champions, hospitals often provide support for leadership training or attendance at national quality conferences, which helps broaden perspectives and raise awareness in areas such as systems and change management. Physician respondents spoke of the importance of hospitals investing in training through courses and seminars to create "true believers" in quality improvement. The more forward-thinking hospitals have succession plans in place for their quality leaders to identify younger physicians who need exposure and education in QI to eventually assume the quality mantle.

Several respondents recounted successful experiences converting skeptics -- physicians who initially criticized the purpose and methodology of QI initiatives -- into champions. Strategies included bringing skeptics into the process early and soliciting their input. For instance, one CNO described how hospital staff worked with a physician who was critical of the Joint Commission's National Patient Safety Goals and the hospital's EMR to ensure he was thoroughly trained and could see the benefits. That physician, who had been an initial skeptic, now reportedly "beats the drum for the whole thing." However, at some point, as one CMO stated, "You have to keep moving forward and not spend too much energy on the holdouts."

Effective Communication Spurs Involvement

When soliciting physician involvement in hospital quality improvement, clear communications and effective messaging are essential. Many hospital executives found they were frequently dealing with an "educational deficit" -- many physicians did not understand QI or its importance, which contributed to their reluctance to participate. Strategies hospitals have used to communicate about QI include one-on-one meetings, newsletters, posters, and e-mails.

A particularly effective message frames quality improvement as beneficial for patients. If hospitals can show physicians that QI activities result in better patient outcomes, respondents believed participation becomes appealing. As one respondent noted, "If physicians understand that it's not about a regulatory or administrative requirement, but... it's about the care they're providing patients, they're all over it, they're very enthusiastic." Other persuasive messages include how QI will ultimately protect physicians' time by improving efficiency and how poor quality costs money and affects the hospital's reputation, which could also impact physicians' own reputations and bottom lines.

Hospital staff can also maximize physician involvement by recognizing that physicians have limited time for QI and being strategic about using that time. Strategies include inviting physicians only to meetings that result in concrete decision making, and scheduling meetings well in advance during early morning or evening hours to accommodate physicians' clinical schedules.

Once physicians do agree to participate, respondents stressed the importance of hospital leadership providing recognition and positive feedback -- an area where several respondents felt their hospitals fell short. For physicians to participate in QI, it often means voluntarily giving their time without compensation; they want to be recognized by hospital leadership for that sacrifice. To address this, some hospitals have used strategies such as publicly posting performance data, holding poster sessions for visibility, and encouraging physicians to present their work to the broader staff.

Implications

While hospitals are working to improve their quality of care and are making incremental gains, considerably more progress is achievable. Recognizing that physicians are essential to quality improvement efforts, it is unlikely that significant advances can occur unless physicians are more effectively integrated into the process. Because many physicians are spending less time in the hospital and are increasingly reluctant to volunteer their time to hospital activities, developing effective strategies to engage physicians in QI will become even more important.

To identify and promote policies and practices that encourage hospitals and physicians to collaborate effectively on results, it is important for policy makers driving the national health care quality improvement agenda to focus on: rationalizing the demands placed on hospitals and physicians, concentrating on a limited number of QI initiatives that demonstrate the greatest promise for meaningful improvement and striving for consistency across programs; creating mechanisms to facilitate hospitals' efforts to leverage data for improving patient care quality, such as centralized data repositories; and establishing financial and other incentives that best support hospital quality improvement while also examining state and federal regulations, such as gainsharing prohibitions, that may impede hospitals' engagement of physicians in quality improvement.

Data Source and Funding Acknowledgement

To examine physician participation in hospitals' quality improvement activities, information was collected from hospitals in four communities participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality Program -- a program focused on performance reporting, quality improvement by health care providers, and consumer engagement on health care quality issues. The four communities are Detroit, Memphis, Minneapolis-St. Paul, and Seattle. In each community, up to four of the larger hospitals were selected for interviews, totaling 13 hospitals. To provide a range of perspectives, chief executive officers, chief nursing officers, chief medical officers, and directors of quality improvement were interviewed. Physicians identified by hospital leadership as quality improvement champions were also interviewed, along with respondents representing relevant national and state organizations knowledgeable about the issues. Findings are based on semi-structured telephone interviews conducted by two-person interview teams between September and December 2008. A total of 53 interviews were carried out, and Atlas.ti, a qualitative software package, was used to analyze the interview data.

This research was funded by the Robert Wood Johnson Foundation.

Sources and Further Reading

Centers for Medicare & Medicaid Services — Hospital Quality Initiatives — CMS hospital quality measurement and reporting programs, including the quality data collection requirements discussed in this research.

Agency for Healthcare Research and Quality — Hospital Quality and Patient Safety — AHRQ resources on evidence-based quality improvement strategies, patient safety goals, and hospital performance measurement.

Robert Wood Johnson Foundation — Aligning Forces for Quality Program — The RWJF program that funded this HSC research on hospital-physician collaboration for quality improvement in four communities.

Health Affairs — Physician Engagement in Hospital Quality Improvement — Peer-reviewed research on the challenges and strategies for engaging physicians in hospital-based quality improvement initiatives.

JAMA Network — Crossing the Quality Chasm and Hospital Care — The Institute of Medicine's landmark Crossing the Quality Chasm report, referenced in this study as a catalyst for hospital quality improvement efforts.