International Journal for Quality in Health Care 15:101-102 (2003)
© 2003 International Society for Quality in Health Care
Editorial |
Quest for physician practice improvement
Texas A&M University Systems Health Science Center, Bryan, TX, USA
North Shore–Long Island Jewish Health System, Great Neck, NY, USA
The year 2003 dawns on an exciting vibrant progressive quest for the science of medicine. This quest has not disappointed as we stand on the threshold of new genomic manipulation of genetic engineering, virtual reality surgery, etc. The profession has had champions of evaluating how well we deliver the science of medicine since before Hippocrates. Centuries have witnessed physicians since Galen uttering ‘Primum non nocere’ and espousing the principles embodied in that familiar phrase. However, physician practices worldwide are an array of heterogeneity. Differences may be found in specialty, sub-specialty, locale, practice type, patient mix, work-hours, work-habits, payment arrangements, and national expectations, yet the art and science of medicine, the profession of medicine, is similar in most individual physician–patient encounters. Collectively across nations we have begun to evaluate how to respond to the increasing demand for external accountability of health care processes and outcomes at each health care delivery site understanding the differences just outlined.
The increased interest or demand should not surprise health care professionals. Innate human interest in health, the explosive growth of medical knowledge, therapies, treatments, and technologies, flamed by the increasing demand for access to the latest knowledge, and computer/internet capabilities is perhaps surpassed only by the growth of the financial burden of the health care systems world wide. This combination of intense personal and community interest combined with the required significant financial resource allocations, the perceived loss of ‘autonomy’ by physicians and the recent widely publicized reports of inconsistent and variable quality and access are some of the drivers of this increased demand for accountability and responsibility. The recent IOM reports, ‘Quality First: Better Health Care for All Americans’, ‘First Do No Harm’, ‘Crossing the Quality Chasm’ and ‘Envisioning the National Health Care Quality Report’ delineate all too clearly many of the issues in the delivery of quality health care.
The role of external assessment of health care in Europe, examined by the ExPeRT project was described in this journal in June 2000 [1]. In this ExPeRT summary, Dr Shaw describes four currently utilized European models of external quality assessment systems: visitatie, accreditation, European Foundation for Quality Management, and the International Organization for Standardization. Dr Shaw further examines the potential for ‘planned opportunistic collaboration of the models that could increase efficiency and reduce duplication in the external quality improvement market’. He further implores us to consider ‘development of a common model for health care quality regardless of statutory responsibility or legal endorsement’.
The Lombarts and Klazinga paper in this issue, ‘Supporting Dutch medical specialists with the implementation of visitatie recommendations: a descriptive evaluation of a two-year project’, describes the complexity of improving care processes at the physician practice level. The described visitatie objective is ‘to improve the quality of patient care by supporting the implementation of practice-specific visitatie recommendations’. Peer review in Holland emphasizes professional self-regulation annual review by a senior medical officer, compulsory Continuing Medical Education, mandatory audits to demonstrate compliance with standards, participation in external peer review and the visitatie. The specialty societies in the Netherlands have developed and executed the doctor-led and doctor-owned peer review system designed to assess medical care quality. The professionally owned visitatie model is conducted, however, in the style of accreditation visits done by external quasi-regulatory bodies in the accreditation model of evaluation. Its focus is primarily on the effectiveness of organization, policy, procedures and processes rather than on clinical effectiveness or outcomes. The visitatie ends with a report with recommendations for improvement and the physician or physician group is advised to implement the recommendations. The variable implementation of such recommendations is not unlike the findings in other countries [2–4]. The current study, acknowledging the heterogeneity of practice types and resources of practices, clearly delineates the complexity of comparison and implementation of change at the practice level. It clearly defines the barriers to include; knowledge and acceptance of specialists’ recommendations; leadership; incentives; financial, regulatory and time resources; motivation, as well as the will, skill and knowledge of how to implement change given the present demands of medical practice. It is further noteworthy that the visitatie model is pre-selected to evaluate policy, procedures and processes of practices and not necessarily the clinical processes and outcomes of practices. The descriptive evaluation design of this implementation study clearly delineates the complexity and the paucity of published scientific literature of this type of endeavor. With practices selected for their willingness to attempt change implementation it is important to note the tools, time, resources and effort to implement change was considerable and effected mixed results.
In the US, the American Board of Medical Specialties has encouraged their components to begin a process of continuous professional development for board recertification. The American Board of Internal Medicine, for example, has proposed a multi-faceted evaluation for recertification that would require ‘proof of professional, cognitive expertise tested by secure examination, life-long learning and periodic self-assessment, and evaluation of practice performance’ [5]. This process for many of the reasons outlined in the current study has met with significant resistance by physicians.
Daley’s ‘Physicians Clinical Performance Assessment: The State of the Art’ [4] clearly delineates the limitations of individual physician level assessment for external reporting ‘for the purposes of physician competence assessment, patient choice and rewarding of physician excellence’. This same report however clearly delineates the usefulness of such assessment for the purposes of continuous clinical quality improvement.
The Daley paper and the current Dutch study further suggest yet another opportunity for the medical profession to control its own destiny by planning, collaborating and developing an ‘internal practice assessment system’ that will be clinically relevant, professionally rewarding and useful for improving clinical outcomes at the practice level. The assurance of efficient, effective and efficacious practice policy procedure and processes may be an important first step toward improving clinical outcomes. It certainly could help with time management and the development of the skills and tools for practice improvement implementation.
Let us again acknowledge the complexity and variability of health care delivery; physician–patient human-to-human interaction; controllability of medical outcomes; the paucity of incentives for behavioral change; inappropriate resource allocation/reimbursement; the variability of patient acceptance; legal liability; economic pressure for productivity; the requirement for process change; the lack of readily accessible means of adequate data and data sharing to change the way we deliver health care individually or collectively in physician offices: we further believe that we as a profession with our kindred health care professions, nursing, etc., are the only ones with sufficient fundamental knowledge to adequately and accurately move forward in improving the science of health care delivery.
Should we not focus on what we know and what we can do as a profession to move cautiously forward in applying the same rigor of investigation understanding the variation of healthcare delivery in physician offices, as we do in developing evidence-based knowledge? The Physician Consortium for Performance Improvement has defined attributes, criteria and appropriate disease specific performance measures which could be self-selected for a particular group or individual practice to begin the processes of defining continuous improvement of care in ones own office. The presently available information technology offers the medical profession the ability to engage in performance improvement and assessment at the individual practice level. Performance improvement that leads to better patient outcomes must become a priority. The ever-increasing success and complexity of medical science will render all else obsolete unless we can learn to more effectively utilize quality improvement methodologies. The very success of the medical profession may be the Achilles heel in ensuring the delivery of this science succinctly, consistently, equitably, reliably and verifiably.
The understanding of variation in health care delivery outcomes for physician offices is a science in its infancy. Aggregated data with standardized numerator and denominator performance measures across all levels of practice might begin to produce data that with appropriate study could define appropriate variation in all types of medical practice.
Goethe’s quotation, ‘Knowing is not enough, we must apply. Willing is not enough but we must do’ at the end of the day is still appropriate.
References
- Shaw CD. External quality mechanisms for health care: summary of the ExPeRT project on visitatie, accreditation, EFQM and ISO assessment in European Union countries. Int J Qual Health Care 2000, 12: 169–175.
- Palmer H, Wright E, Orav E, Hargraves J and Louis T. Consistency in Performance Among Primary Care Practitioners. Med Care 1996, 34 Suppl: 52–66.
- Jencks SF, Cuerdon T, Burwen DR, et al. Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. J Am Med Assoc 2000; 284: 1670–1676.
- Daley J, Vogeli C, Blumenthal D, Kaushal R, Landon B, Normand S. Physician Clinical Performance Assessment: The State of the Art. Issues, Possibilities, and Challenges for the Future. The Institute for Health Policy Massachusetts General Hospital 2002; pp 50–64.
- American Board of Internal Medicine. A New Approach to Recertification. 15 September 2002.
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