Why Physicians Have No One to Blame for Poor Quality

Juan Reynoso, Jr.

Juan Reynoso, Jr. , MD

Regional Director

Published July 31, 2017

An oft-cited criticism of the healthcare quality movement is that it evaluates healthcare providers on factors beyond our control.

Take the emergency department (ED). We providers can't stop our discharged patients from skipping their meds and follow-up appointments and landing back in the hospital. And surely we can't be held accountable if a brusque nurse interaction gives our satisfaction scores a ding.

Or can we?

As a Medical Director, I was in a unique situation in which one physician group managed two very different emergency rooms at hospitals 16 miles apart. It was, (to my geeky scientific brain) a controlled experiment. If the same providers practiced the same medicine at both EDs, we'd be able to see which quality metrics were really under our control.

The experience taught me an important lesson. When it comes to quality improvement, providers can often control more than we think we can.

Here's why I believe it.

A Tale of Two EDs

Our local practice has managed two EDs in the Dignity Health system since 2002. These departments may be sisters, but their pressures, patients, and appearance couldn't be more different.

French Hospital Medical Center is located in the busy college town of San Luis Obispo. It's a technologically advanced facility with an ICU and an ED that sees a lot of complex, highly acute patients. In many ways, working at French feels like working in a tertiary hospital. It's interesting, intellectually challenging, and fast-paced.

Arroyo Grande Community Hospital is just down the road, but it feels worlds away. The road to town winds through cabbage patches. The main street is so sleepy that the hospital's appearance comes as a surprise. Arroyo Grande's ED has more of a "community" feel and treats plenty of colds, rashes, and fussy babies between emergencies.

As stated above, I viewed these sister EDs as an interesting experiment. After all, the providers, processes, and medicine were exactly the same at both EDs. In addition, both were staffed by the same excellent providers who upheld the highest clinical standards and dedicated themselves to continuous quality improvement.

Therefore, any differences in quality and performance would therefore be due to factors beyond our control, right?

Well, what I actually learned is that very little is beyond our control as providers. For example:
  • Patient Satisfaction

A patient in the French Hospital ED once complained to me, “I was at the ED in Arroyo Grande yesterday, and it was a waste of time! Those doctors there, they don’t know what they’re doing!”

Funny, the doctor he'd seen yesterday in Arroyo Grande was me (though I didn't tell him).

But in a way, it made sense. French's ED usually ranked first in Dignity Health when it came to patient satisfaction. Arroyo Grande was usually in the top ten — pretty good for a big health system. But with the same providers and clinical leaders working at both campuses, it seemed weird they weren’t running neck and neck.

It would have been easy to chalk the difference up to confirmation bias (i.e., people seeing what they expect to see). After all, French had an elite reputation, while Arroyo Grande was perceived as more work-a-day.

However, our previous Medical Director had been convinced that the real issues were cultural. He'd been working hard to improve provider-nurse relationships at Arroyo Grande. And when I took the job, that torch passed to me.

So I followed his example of meeting monthly with the nurses to discuss issues and hear feedback. My partners and I also set out to build bridges. "We really can't do it without you," was our mantra. We began to extend our continuing education programs to the nurses so we could all learn together.

Gradually, tensions in the department eased. Nurses and providers began working together on process improvement and experiencing wins. A year later, the nurses were happier, walking around with their heads up and their shoulders down.

Arroyo Grande's Chief Nurse Executive describes our current working relationship in the following video. (She appears at 1:37 in this compilation.)

I'd figured improving nurse-provider relations might mean a modest improvement in patient satisfaction. I was wrong. Satisfaction scores at Arroyo Grande rocketed up beyond all expectations. Each month, they now jockey with French for No. 1 in the system.
  • Operations

French may have had a natural advantage in the patient satisfaction department. But process innovation has generally been Arroyo Grande's bag. With fewer personnel and patients involved, we often have an easier time getting initiatives off the ground there.

A good example is lab turnaround. There was a point when Arroyo Grande made some process improvements and was totally killing it on that metric. However, we weren't getting the same traction at French.

I decided to use a little sibling rivalry to my advantage.

"You know," I told French's lab manager. "Arroyo already has their operations committee up and running. They shaved 10 minutes off their turnaround time to discharge. Oh, and their lab is 200 yards from the ED!"

Well. This lab manager was not about to be one-upped. Within weeks, he reengineered his workflow, and his lab became the fastest in Dignity Health.

We followed a similar pattern when starting our PA/NP program. Initially, the advanced providers worked only at Arroyo Grande. But once administrators at French saw the gains in productivity and patient satisfaction, they too embraced advanced providers.

So it's fun to watch the friendly competition between these hospitals. But it also drives home that size — big or small — should be no obstacle to quality. Having great partners with great ideas matters more. (And in fact, we've managed to standardize our processes across both sites with very few adjustments.)
  • Provider Satisfaction

We all want to create workplaces that encourage provider retention and career longevity. So it's worth noting that our physicians and advanced providers really benefit from exposure to these two distinct clinical environments.

For one, working in two very different EDs balances and refreshes us. After a hectic shift seeing highly acute elderly patients at French, we can recharge a bit treating kids and families at Arroyo Grande. And after a day of Arroyo Grande's prescription refills and sniffles, we're thrilled to get back to the "action" at French.

Having two workplaces also enlarges our intellectual and social worlds. We work with two different groups of nursing staff and ancillary staff, which ultimately means that we have many more work friends. And when we need advice, we have two sets of perspectives we can draw from.
  • Human Capital and Innovation

Flexible resource allocation is yet another benefit of staffing two sister EDs with one group.

Our site management team is a good example. Instead of finding two different Directors of Quality, we appoint one to oversee both EDs. The outcome is more efficient results with one standard applied at both sites. This arrangement also makes it easy to share new learning from one ED to the other. It helps us maintain high standards and constantly discover best practices.

(We follow a similar model with our Director of Risk and Education, Advanced Provider Lead, and other leadership positions.)

Good Medicine Always Wins

A Dignity Health administrator once asked me, “Do you think you practice medicine differently at these hospitals? Is there a difference in how you behave and approach people? What about your workups?"

My answer: I really don't think so. I’m still a physician at every campus. We all are.

If anything, this "controlled experiment" between French and Arroyo Grande shows that when it comes to quality, provider quality and motivation often trumps environment and circumstance.

This isn’t to say that quality improvement comes easy. It takes a lot of heart, expertise, and commitment. But having seen the same processes work for these most disparate of sister hospitals, I'm convinced we providers have more power than we realize.

So let's stop talking about what we can't do because … patients, resources, management, nursing, the building, the state, the feds, etc.

Let's get out of our own way and change stuff.

To read more about empowering providers to effect change, check out these posts:

Partnering to improve patient lives

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