Granting physician privileges

A friend of mine who’s a colorectal surgeon in a city far from my home in Utah told me a fascinating story recently about how colonoscopies are performed in the hospital where he practices. He said he’s done over 22,000 colonoscopies without a single bowel perforation, and he regularly gets calls to run in and fix perforations caused by another doctor in his hospital. His colleague’s perforation rate: 1 in every 1,000 procedures.

I asked my friend, “Does this doctor talk with you about how he could improve his outcomes and cause less harm?” My friend said: “No. There’s no incentive for him to do that. He gets paid the same whether there are perforations or not, and why would he want to call attention to his not-so-stellar outcomes?”

I have to reach for my blood pressure pills whenever I think of that conversation. That variation in outcomes is frightening. I think: Shouldn’t the trustees of my friend’s hospital be asking questions about his colleague’s perforation rate? Isn’t that our job as trustees? 

Monitoring outcomes

Health care is the only industry in which providers can break things and charge you for fixing them. Can you imagine what you’d do if you brought your car in for an oil change and your mechanic said, “Hey, while we were changing the oil, we broke your windshield, so we can’t give you your car back for a couple of days, and instead of $30, it’ll cost you $300.” Would you pay it? Of course not. You wouldn’t stand for it.

Just to be clear: My suggestions aren't meant to be punitive. They're about continuous improvement, patient safety and reducing harm. This requires administrative and physician leadership in promoting an evidence-based environment where leaders set patient-centered goals, physicians collaborate to eliminate variation and reduce harm, and trustees not only ask the right questions but set standards of accountability. Such a process of measurement, improvement and accountability will not only improve patient safety and clinical outcomes but will also mitigate the spiral of health care costs that now represent over 18 percent of our nation’s gross domestic product.

That leads to my point. Trustees who oversee how physicians earn privileges at America’s hospitals should move to a system based on physician outcomes and clinical effectiveness. 

What is needed is more transparency around outcomes, complying with proven protocols and reducing variation in outcomes. Trustees are accountable for the quality of care provided in their hospitals. They should ask for this information. The title “trustee” carries with it great responsibility. The community is putting its trust in a small group to ensure the well-being of our friends, co-workers and neighbors. Trustees, along with physicians and administrators, should drive toward zero harm in health care. In the field, we should start sharing outcomes data with trustees and ultimately with the public.

Data vacuum

Americans generally don’t have access to quality data. When they need a doctor, they ask their friends and family: "Do you like your doctor? How does she treat you? How easy is it to get an appointment?" Or, if they’re technologically adept, they log on to a physician rating service — and that leads to more problems.

The vast majority of rating services rate only one thing: How much patients like their doctors. The rankings are about patient satisfaction, period. And even then, the rankings often aren’t statistically significant. I clicked on one popular website before I wrote this Viewpoint and saw a long list of doctors who earned “five star” ratings — the site’s highest possible score. How many patients provided reviews? Eight for one doctor, 60 for another, 12 for another, and, for one five-star doctor, one patient wrote a review.

My conclusion is: Most online rankings are based on such small sample sizes that they’re meaningless — and that doesn’t include the fact that they don’t measure key quality factors in the first place. You could still end up being the 1,000th patient of my doctor friend's colleague.

So, what’s a better way to grant physician privileges? The answer comes from W. Edwards Deming, the noted quality guru, who said, “In God we trust — all others must bring data.” 

People want to have some way to decide what doctor to see, and the absence of meaningful data has created a vacuum that entrepreneurs tried to fill by developing today’s patient satisfaction–based physician rating services. But the ratings have nothing to do with outcomes — and I think the vacuum will continue until the leaders of American health care step up.

Reducing variation

For most hospitals, it may be difficult to collect, analyze and share data. There’s no Easy Button that will help us change. Health care, a $3 trillion industry, is as hard to turn around as a fleet of battleships, and two strong forces reinforce the resistance. I call them "ME" — money and ego — and health care providers and leaders have large amounts of both invested in the current system. But if trustees, physician leaders and administrators join together, we can improve.

Outcomes-based privileging could work just like choosing a physician should work. Our physician friends can select the measures for every specialty. We could work together to set filters that evaluate physicians based on the number of procedures they’ve performed, their readmission and infection rates, the number of follow-up emergency department visits their patients make, their compliance with protocols or best practices, and so forth. We certainly have the capability and computing power to adjust for morbidity, age, obesity, smoking and other factors that may complicate the results. Then, using that data, we’d see how doctors rate — and so would they, which would increase their incentive to practice medicine as effectively as possible.

Outcomes measurement is not a new concept. It has been featured in Harvard Business School case studies and various articles. Trustees should put it to use to improve health and health care.

My hope is that we’ll create a culture where my friend the colorectal surgeon, who’s never perforated a bowel in 22,000 colonoscopies, will sit down with all of his colleagues who do colonoscopies on a regular basis and compare outcomes in order to reduce harm. His friend whose perforation rate is 1 in every 1,000 procedures will ask: "What makes the difference? What should I do differently?"

The idea is not to fire the underperforming doctors but to collectively reduce harm and suffering by eliminating variation. It’s about establishing a culture of continuous improvement in outcomes, where everyone’s ranking is based not only on how nice they are to their patients but, more important, on how well they deliver high-quality care.

One of my favorite doctors shared some advice appropriate for all of us who serve as trustees. His name was Dr. Seuss, and he said: “Unless someone like you cares a whole awful lot, nothing is going to get better. It’s not.”

Shahab Saeed, P.E. (ssaeed@westminstercollege.edu), is an adjunct professor of management and trustee of Intermountain Healthcare in Salt Lake City. He has also served as the chairman of the board of Intermountain Healthcare’s Central Region and as a faculty member at the Institute for Healthcare Improvement.