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By Steve Berkowitz
Almost every chief medical officer (CMO) that I work with in my advisory program has encountered at least one situation in the hospital every year that requires a significant intervention with a member of the medical staff. Whether the precipitating event is a disruptive physician, an incompetent provider, or simply a sensitive political situation, the leadership faces challenges as to what is the best way to provide a fair and due process that will achieve the most effective result. Having encountered many of these incidents during my tenure as a CMO and a consultant, I have found it useful to apply the following three rules to the interventions that I have had to consider. I review these rules regularly with fellow CMOs. I have discussed these previously in publications, but with the new year coming on, it is worthwhile to revisit these three simple rules: Rule 1: Patient safety comes first. This should be self-evident, and something that is automatically assumed. We have an obligation as physicians and as health care leaders to always advocate in the best interests of our patient. When evaluating the pros and cons of any potential decision, we should always opt for the choice that offers the safest possible environment for our patients. Therefore, prior to considering any decision in these cases, I first ask myself “is the patient (or any future patients) at risk”. Patient safety is the low bar that must always be achieved. Regardless of the ultimate decision, patient safety rules! Rule 2: Always follow your bylaws and procedures-. One of the most common reasons for getting into trouble in any potential intervention is that someone did not follow the established rules. Most of us avoid reviewing the medical staff rules and regulations, and when we do look at them, they could well serve as a cure for insomnia. Having said that, we must always remember they were created for a very important purpose— and this physician intervention is specifically one of those purposes. Whoever is quarterbacking the decision process, usually the CMO, must be totally familiar with every existing rule, regulation, bylaw and precedent. The first step in the process is NOT to do a knee-jerk reaction, but rather to immediately refresh yourself with the rules. Unless you are in immediate extreme danger, and that is rarely the case, take a few moments to reacquaint yourself with those rules and bylaws up front. This review time is well spent. Also, in every step of the process, make sure that each participant, including the physician being reviewed, has a copy of those rules and understands them fully. If the situation ever goes to some form of legal review or litigation down the road, one of the first things that will be looked at is “did you follow all of your own rules and regulations?”. Do not get bit by that one. Not following the rules opens you up to all sorts of problems, all of which distract from the original offense that you are trying to manage. But rather than being negative, look at the converse: the rules are your friend during this process. Following the rules is your best protection from an adverse procedural event or adverse outcome, and your best pathway to get a reasonable remedy. Never assume you know the rules; always check them out and be sure you are comfortable with them. If there is any doubt, immediately seek legal counsel. Rule 3: Implement the least disruptive solution that ensures Rule 1. Following these rules you have first considered the patient safety aspect, and then have followed all the rules during the process. Now it is time for the remedy. What is the most appropriate action to resolve the issue? With any intervention, there is often a continuum of potential remedies. For example, for an offending physician, it may range from a simple reprimand to summary suspension—or anywhere in between. Here is where Rule 3 is so important. I always advise clients who, given a spectrum of potential responses, choose the least disruptive option that will ensure patient safety. Ensuring patient safety must trump any potential concerns for the welfare of the individual physician, or even the hospital. The sports analogy is that whether you win by 50 points or 1 point, you still win. The “win” is to maintain patient safety. Although you want to minimize the impact of the decision on the organization and on the physician, it should never sacrifice the safety of the patient. Over the years, I have found the application of these principles to be very helpful. Even though I started doing this almost 30 years ago, I feel that the three rules are still relevant. Looking for your next healthcare speaker? Get in touch with us today to make your healthcare event a success!
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By Steve Berkowitz
Hardly a conversation goes by between myself and a fellow Chief Medical Officer where one of us does not bring up an issue regarding a difficult physician on the medical staff and how best to deal with it. Whether the presenting issue is disruptiveness, inappropriateness, incompetency, impairment or anything else, the medical staff leader ultimately faces the dilemma on how best to resolve the situation. These cases are frequently uncomfortable on multiple levels for the medical staff leadership: in the areas of personal involvement, professional disagreements, and lack of individual experience on the part of the medical leader in dealing with the process. Over the years I have developed a few simple rules and questions that have been helpful to me to reach a reasonable remedy in the great majority of the situations that have arisen in my roles of Chief Medical Officer and Consultant. First, I like to apply four straightforward rules: Rule 1: Patient safety comes first. Rule 2: Follow your established Bylaws, policies and procedures. Rule 3: Involve legal opinion early on. Rule 4: Implement the least disruptive disposition that will satisfy Rule 1. As we go through the process, regardless of the nature of the complaint, I like to address the following hierarchical questions in order of severity: 1. Is there an egregious issue going on that constitutes an immediate threat to patient safety and therefore may require a summary suspension or other immediate action? This is the most extreme case and fortunately the most rare. If there is a clear danger to the patient, immediate measures are necessary. We must be sure to protect all patients, present and future, from harm. When I am comfortable that the case does not rise to this level of severity, I go to the next question: 2. Is there an aspect of this case that is reportable to the NPDB, state Medical Boards, or other agency? It is important for the medical leader to be familiar with what must be reported on a national level and with the particular state medical board. A legal opinion is essential if there is any doubt to whether the offense qualifies for immediate notification of any of the agencies. If there are no reportable issues, it generally gives us more flexibility down the road in the resolution process. Not the least of which, it opens up the option of voluntary resignation by the physician as a possible outcome. 3. Is our process completely in compliance with the Bylaws/ Rules and Regulations?Following the established policies and procedures are necessary throughout every step of the process and every participant in the action must be familiar with them. Many of the problems that are encountered through this process are directly due to not following established procedures, rules and policies. We must be sure that the physician is completely aware of the procedures and the resulting consequences of not adhering to the action plan. Of course, the appropriate confidentialities must be maintained throughout the process. The goal is to have a comprehensive action plan that all parties understand, with pre-established goals and timelines. 4. Is the situation remediable? What has been done with the physician to date. Has everything been appropriately documented? Are we following the appropriate graded steps in dealing with the situation? Have we seen improvement toward the desired outcome and is the physician motivated to take the necessary steps down the road so that the particular incident will not occur again. Ultimately, we come to the disposition and the application of my Rule 4: what is the least disruptive option that ensures the appropriate patient safety? As we consider potential interventions along the continuum of doing nothing at the one extreme and immediate summary suspension at the other extreme, I like to implement the least severe option on that continuum that accomplishes our overall goal of patient safety. Obviously, the appropriate intervention is very individual and based upon the specifics of the case. I strive to do everything that I can for the physician. I very much respect that a physician’s livelihood may be at stake, but even more, I respect that the patient should never be put in potential harm’s way. What is the least disruptive remedy that gets the job done? Managing medical staff interventions is a very complicated topic, and this article was simply meant to outline the graded steps that should be taken in order to achieve the best outcome for all parties involved. There is much more to say on this matter, but I have found the application of these rules and questions has kept me out of trouble administratively and has led to the best outcome for the physician and the patient. Looking for your next healthcare speaker? Get in touch with us today to make your healthcare event a success! By Steve Berkowitz
Hardly a conversation goes by between myself and a fellow Chief Medical Officer where one of us does not bring up an issue regarding a difficult physician on the medical staff and how best to deal with it. Whether the presenting issue is disruptiveness, inappropriateness, incompetency, impairment or anything else, the medical staff leader ultimately faces the dilemma on how best to resolve the situation. These cases are frequently uncomfortable on multiple levels for the medical staff leadership– in the areas of personal involvement, professional disagreements, and lack of individual experience on the part of the medical leader in dealing with the process. Over the years, I have developed a few simple rules and questions that have been helpful to me to reach a reasonable remedy in the great majority of the situations that have arisen in my roles of Chief Medical Officer and Consultant. First, I like to apply four straightforward rules: Rule 1: Patient safety comes first. Rule 2: Follow your established Bylaws, policies and procedures. Rule 3: Involve legal opinion early on. Rule 4: Implement the least disruptive disposition that will satisfy Rule 1. As we go through the process, regardless of the nature of the complaint, I like to address the following hierarchical questions in order of severity: 1. Is there an egregious issue going on that constitutes an immediate threat to patient safety and therefore may require a summary suspension or other immediate action? This is the most extreme case and fortunately the most rare. If there is a clear danger to the patient, immediate measures are necessary. We must be sure to protect all patients, present and future, from harm. When I am comfortable that the case does not rise to this level of severity, I go to the next question: 2. Is there an aspect of this case that is reportable to the NPDB, state Medical Boards, or other agency? It is important for the medical leader to be familiar with what must be reported on a national level and with the particular state medical board. A legal opinion is essential if there is any doubt to whether the offense qualifies for immediate notification of any of the agencies. If there are no reportable issues, it generally gives us more flexibility down the road in the resolution process. Not the least of which, it opens up the option of voluntary resignation by the physician as a possible outcome. 3. Is our process completely in compliance with the Bylaws/ Rules and Regulations?Following the established policies and procedures are necessary throughout every step of the process and every participant in the action must be familiar with them. Many of the problems that are encountered through this process are directly due to not following established procedures, rules and policies. We must be sure that the physician is completely aware of the procedures and the resulting consequences of not adhering to the action plan. Of course, the appropriate confidentialities must be maintained throughout the process. The goal is to have a comprehensive action plan that all parties understand, with pre-established goals and timelines. 4. Is the situation remediable? What has been done with the physician to date. Has everything been appropriately documented? Are we following the appropriate graded steps in dealing with the situation? Have we seen improvement toward the desired outcome and is the physician motivated to take the necessary steps down the road so that the particular incident will not occur again. Ultimately, we come to the disposition and the application of my Rule 4: what is the least disruptive option that ensures the appropriate patient safety. As we consider potential interventions along the continuum of doing nothing at the one extreme and immediate summary suspension at the other extreme, I like to implement the least severe option on that continuum that accomplishes our overall goal of patient safety. Obviously, the appropriate intervention is very individual and based upon the specifics of the case. I strive to do everything that I can for the physician. I very much respect that a physician’s livelihood may be at stake, but even more, I respect that the patient should never be put in potential harm’s way. What is the least disruptive remedy that gets the job done? Managing medical staff interventions is a very complicated topic, and this post was simply meant to outline the graded steps that should be taken in order to achieve the best outcome for all parties involved. There is much more to say on this matter, but I have found the application of these rules and questions has kept me out of trouble administratively and has led to the best outcome for the physician and the patient. Looking for your next healthcare speaker? Get in touch with us today to make your healthcare event a success! By Steve Berkowitz
Many of us are now looking forward to next year’s budget, strategic plan, and either updating or enhancing the quality dashboard. Additionally, this time of year, there may be new Board members and medical staff officers, some of whom may need to be educated on the above processes, in particular, the quality improvement initiatives. At a minimum, one needs to better understand the quality dashboard, the indicators which comprise that dashboard, and the process by which the system will improve performance. It is easy to get overwhelmed with quality indicators. Many health care systems track hundreds of them on a regular basis. Ultimately, these indicators should roll up into a single dashboard. When educating new Board members, it is tempting to have them “drink from the firehose” by showing them all of the indicators that the system is tracking, and it is not hard to quickly lose the audience in a sea of data and acronyms. Oftentimes, and sometimes out of shear frustration, a prudent Board member will ask the question: “How did you determine which of these indicators to incorporate into the dashboard?” So, both the time of year and the need to educate new leadership makes now a good time to revisit the concept of “Indicators for Indicators”...Specifically, out of the myriad of indicators that are tracked, how do we pick out the cherished few that will be reported to the Board and management on a regular basis? Having worked with many systems over the years, the following points have greatly assisted me in transforming this mass (or morass) of data into a useable, effective dashboard that will drive the appropriate results necessary to move the organization forward. 1. The dashboard should be just one page (and not done so with micro-print!) It should go without saying that the document is concise, easy to read, and will enable the readers to quickly focus onto the most important indicator at the time. Often, the indicators are color-coded red, yellow and green, so that the outlying indicators are quickly apparent. 2. The dashboard should consist of 3-6 Value categories, as outlined by the organizations mission, vision and values. Examples would include: patient safety, quality outcomes, cost-effectiveness, citizenship, mission goals, etc. 3. The total number of indicators to populate the system dashboard should be distilled down to approximately 8-12 individual data entries. 4. All the indicators for the individual members or departments of the system should roll up into a common dashboard. Having said that, I do acknowledge that there may be specific issues within an individual entity that must be managed, and that they may deserve a place on the local dashboard. But ultimately, everything that is monitored and managed should roll up to the ultimate success of the organization, and correlate with the entries of the system dashboard. 5. The dashboard is a dynamic document that needs to be continually managed and massaged as the organization and the health care climate changes. Individual indicators will change with time, either because the appropriate result has been obtained, and the indicator is no longer needed, or a more important indicator has arisen to take its place. Incidentally, the Value categories should not change much through time 6. The ideal indicator should have the following attributes: a. The indicator must be significant to the organization. Put simply, if the organization is going through the effort to obtain and manage this indicator, the successful accomplishment of that indicator must have a significant positive effect on the system. Otherwise, it is a waste of time. The fundamental premise is that the successful accomplishment of the components of the dashboard will result in the success of the system. If this argument cannot be made, it is not worthwhile to include that data as part of the dashboard. b. The indicator must be measurable. The organization must have the capacity to appropriately abstract and obtain the indicator. Typically, many of the indicators are obtained through the existing EMRs. c. The indicator must be reasonably objective. There should be a common, agreed-upon, definition for that indicator. Any ambiguity should be minimized, if not eliminated. There should be no ability to “game” that number to benefit the organization. d. The indicator target must be obtainable with reasonable effort. It does no good to track an indicator that cannot be accomplished. The targets should be aggressive but doable by the organization. I have found the above thoughts to be very useful, both in the day to day operations of the system, and as part of the ongoing leadership educational program. Looking for your next healthcare speaker? Get in touch with us today to make your healthcare event a success! By Steve Berkowitz
We have seen a great deal of progress in getting the patient more involved with his/her health through the process of health literacy. As defined by HHS almost ten years ago, health literacy is “the degree to which individuals have the capacity to obtain, process, and understand health information to make appropriate health decisions”. In 2013, the Institute of Medicine further outlined three priorities in health literacy:
We have seen numerous local, regional and national efforts toward the achievement of these goals. Key components of health literacy programs include knowledge of the individual’s health and risk factors, knowledge of insurance, interaction with health care providers, and a better understanding and utilization of social media. At first glance, these efforts seem to be an elucidation of the obvious. Of course, the patient should be very involved with his/her care. After all, the patient is the one with the medical condition and the patient is the one who will be the recipient of the management and treatment. Over my career, it was striking to hear so many patients tell me, "whatever you say, Doc." Why would so many patients completely defer to me, a third party, the decision to do some potentially very invasive, and sometimes disfiguring, things to their bodies? Even if I may be the “expert” in the matter. Why should I bear that responsibility alone? Maybe I am simplistic, but shouldn’t the patient take primary responsibility for his/her health and welfare? Certainly, any efforts at true population management are doomed to failure if the patient does not assume a key role in the process. So, toward that end, I obviously support efforts at health literacy. After all, knowledge is the first step in informed decision-making. At least in theory, the more knowledge shared amongst all stakeholders, the better the outcome. But that is only the beginning. Knowledge is a great initial step, but knowledge in itself does not guarantee a favorable outcome. Present efforts in health literacy have focused on the first part of the HHS definition, “the degree to which individuals have the capacity to obtain, process, and understand health information”. Now we need to get to the third part of that definition “and make the appropriate health care decisions”. The clinical outcome is the endpoint of a series of decisions and actions. Therefore, health literacy, although a very welcome addition to health care, must go farther. Health literacy must progress to health actuation. The entire health care team– the patient, the caregivers, the entire system– must engage and use this information together. We must work a team to ensure the best outcome. But within this team, the patient must play a key role, and maybe, the most critical role. The knowledgeable patient must progress to an influential member of the health care decision-making team. You and I will be better physicians if the patient is not only health literate, but also health actuated. We will get better outcomes with the patient working with the team. Let’s move from health literacy to health actuation - especially for the patient! Looking for your next healthcare speaker? Get in touch with us today to make your healthcare event a success! By Steve Berkowitz
The scene is all too familiar: a physician in the Medical Group suddenly leaves or develops an extended illness. An atmosphere of panic pervades the clinic. Who will see that physician’s patients? How quickly can we get another physician? Where do we recruit? What do we do in the mean time? All Medical Groups face these situations on a regular basis. Having consulted with many Medical Groups across the country over the years around the issue of recruitment and retention, here are some tips that should be considered by your Group: 1. Develop and Implement a Recruitment Plan for the Medical Group. Ideally, this plan should be in place BEFORE the event. Several factors must be considered in the successful development of this plan. Importantly, it must tie to the overall needs of the Group and must be an integral component of Group’s Strategic Plan. There are several key issues to consider: The Group must first determine which services/specialties are needed within the Group as well as the costs/benefits of providing such services. Then it must be determined if there is a specific need within those services. Multiple issues to consider include the desired/ ideal panel sizes for primary care, productivity assessments for all current physicians, geographical or office coverage issues, and the potential for growth, to name a few. These factors determine the ideal number of physicians for each specialty in a given geography and the Group can objectively determine if there is a gap and whether recruitment is even necessary. The recruitment plan, like the Strategic Plan, should be periodically reviewed and adjusted as the needs of the Group change. 2. Develop a Medical Group Charter. This document defines the ideal physician for the group in terms of the Group’s mission, vision, and values as well as acknowledging the cultural issues, both overt and covert, that exist within the Group. The cultural piece needs to be discussed openly and frankly amongst the providers. For example, does the Group expect high productivity/ high compensation amongst its physicians, or does the Group “set the thermostat” at a lower workload/ lower pay expectation? These cultural expectations are critical to discuss especially as one considers the compatibility of future recruits. The Charter becomes an integral part of not only the recruitment process, but also a part of the compensation/ incentive program for the Medical Group, as those physicians who most embody the spirit of the Charter should be those most rewarded in the compensation plan. 3. Just because a physician leaves the Group does not mean an additional physician should be recruited. A recruitment plan is not a glorified replacement plan. Despite the chaos that can ensue with a sudden physician vacancy, as described above, there is now an opportunity for the Group to reevaluate the need for recruitment. Do not get cajoled into thinking that just because a physician has left, there is an automatic need to recruit another. There may be other options for the Group to consider, such as redistributing patients to other, less busy physicians. 4. Utilize a standardized process for recruitment. As new physicians are added, the Group needs to develop a consistent methodology to most insure hiring the best physician. It is imperative that the recruited physician have a reasonable understanding of what will be expected by the Group. Compatibility with the Group Charter is essential. Group expectations in productivity, on-call and work/life balance must be clearly articulated. It is important that as many members of the Group as possible personally evaluate the applicant. Likewise, the applicant should have the opportunity to interview as many of the physicians in the Group as possible. Both parties must honestly assess the situation and make the best decision objectively. It is OK for either party to disagree and walk away. The worst-case scenario is not the absence of the physician, but rather the “miss-hiring” of the wrong physician. The inappropriate hire can be considerably costly to the group in many ways down the road. 5. Develop a strategy for physician retention. Turnover has a considerable cost in terms of lost patient visits, lost time in diagnosis/treatment of patients, increased workload for the remaining physicians, and the time-consuming and expensive process of finding a physician and acclimating that physician to the Group. By and large, turnover should be minimized. However, one must acknowledge that some turnover is good—not only if there is a quality or competency issue, but also if that physician does not fit in with the culture of the Group, or is not compatible with the values of the Medical Group Charter. But the huge cost of turnover should be recognized by the Medical Group. Physician retention is the best way to minimize the need for recruitment. What is being done by the Medical Group to encourage the good physician to stay? Ideally, recruitment should be reserved for Medical Group growth. Many groups routinely assess the satisfaction of the physicians, and adapt accordingly. Your Group should strive to be the ideal place to practice medicine in the community. Are you creating an environment where the good physician wants to stay? Are symptoms of burnout promptly recognized and addressed? Are there long-term benefits and incentives in the compensation program? 6. Leaving is the final step in the process of being dissatisfied. What are you doing to recognize physician dissatisfaction early on, and what are you doing about it? Many times, appropriate intervention can obviate the need for the physician to leave. There is a great opportunity here for "preventive medicine." Looking for your next healthcare speaker? Get in touch with us today to make your healthcare event a success! |
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