In hospitals across the country, doctors and nurses often feel like small cogs in very big wheels, unable to provide input into how hospital systems function on behalf of their patients. That’s one of many contributors to burnout.
Nine years ago, when I began a new job as an intensive care physician at Christus St. Vincent Regional Medical Center in Santa Fe, N.M., our well-trained physicians and nurses operated as individuals — undoubtedly doing their best, but without consensus or coordination. There seemed to be little attention paid to the systems we used, or to reflection about how clinicians could work together to provide the best care.
The consequences could be seen everywhere. Whether a patient in the intensive care unit stayed on a ventilator or received a trial of spontaneous breathing had more to do with the nurse or respiratory therapist on call that day than with what guidelines and medical studies recommended. My colleagues might have adjusted their clinical practices based on recent scientific evidence — or maybe they hadn’t.
What’s more, the hospital didn’t feel like a happy place. Clinicians were demoralized — it feels terrible to suspect that as an organization, you aren’t providing optimal care. They often seemed to try to cope by distancing themselves from their work and their patients.
Physicians take individual responsibility for the quality of care they themselves provide. But in most health care settings, quality depends not only on what individuals do but also on how systems operate. Physicians, nurses, and other clinicians know full well where the problems and the opportunities lie, and have good ideas for likely solutions. But they are usually too busy caring for their patients one by one to do the hard work of improving systems of care. This is why most physicians are not substantially involved in quality improvement — they may make a token appearance at a project team meeting or two, but tend to remain largely peripheral.
Several years after I started, the hospital implemented — at the request of physicians — a novel quality program that I directed. Called clinician-directed performance improvement (CDPI), it gives paid protected time to front-line clinicians to conduct performance improvement projects they believe are important to their patients. Each service line — surgery, pediatrics, internal medicine, and the like — is represented by a clinical dyad, usually a physician working the equivalent of one day per week and a nurse working half-time. These dyads have centralized support, including data collection, statistical consultation, graphics development, and training in performance improvement. The goal is to enable busy clinicians to effectively improve the quality of care using sophisticated research methods.
This program is unique in two ways. First, while many organizations give lip service to “engaging” physicians in quality improvement, few are willing to make the short-term investments in paying physicians and nurses for their time to do it. Second, most organizations focus narrowly on using externally mandated measures, such as those developed by Centers for Medicare and Medicaid Services, rather than allowing their clinicians to guide quality priorities that respond to needs in their own hospitals. So instead of asking clinicians to engage in the institution’s quality agenda, CDPI gives them the liberty to choose their own performance improvement projects, based on their insights into system problems, expertise, and concerns about their patients.
The changes stemming from CDPI happened rapidly. Suddenly, the hospital was buzzing with project teams researching and planning how best to take care of patients — it was hard to find a free conference room. The obstetrics dyad was working to improve pain management in labor and preparedness for obstetric emergencies. The ICU team was tackling ways to optimize ventilator care and starting physical strengthening in critically ill patients early in their ICU stays. The internal medicine team wanted to start treatment for alcoholism during hospital admission, improve the quality of sleep for hospitalized patients, and reduce the inappropriate use of antibiotics and gastric acid suppressants that contributes to hospital-acquired infections. In the first four years of the program, clinician dyads conducted more than 40 performance improvement projects, with a 92% success rate, defined as achieving statistically significant improvement in the primary metric.
We saw major program-associated improvements in clinical outcomes. Rates of hospital-acquired infections, including C. difficile colitis, ventilator-associated pneumonia, central line infection, and surgical site infection, decreased sharply, as did adverse drug events, duration of mechanical ventilation, and deaths from sepsis. In the first four years after CDPI was implemented, the hospital’s Medicare Star Rating increased from 2 to 5 stars, the highest rating possible. At the same time, financial analyses demonstrated that the program generated a net savings, mainly through the avoided costs of complications and poor outcomes.
A particularly dramatic effect was the remarkable improvement in the morale of Christus St. Vincent clinicians. There is now a far greater sense of ownership and pride in the care we give. These changes in atmosphere are reflected in measured changes: As I describe in an article published Monday in the latest issue of Health Affairs, in the first three years after CDPI was implemented, national surveys showed that our organization’s physician engagement increased fourteenfold in percentile ranking.
I believe that the opportunity to take back ownership of the quality of care delivered in a hospital restores physicians’ professional identities and reconnects them to why they became doctors in the first place.
CDPI was implemented in a 200-bed community hospital that serves an underserved community. That suggests any hospital — not just large, affluent, or academic medical centers — can make meaningful investments in clinician-led quality improvement. The greatest challenge is to make the leap of faith in which the organization commits to truly supporting its clinicians’ quality priorities.
The current national strategy for improving health care relies heavily on accountability based on metrics developed by outsiders. These have been criticized for failing to engage clinicians, among other things. I see this as a fatal flaw. Unless we take advantage of clinicians’ insight and expertise, quality improvement will be a futile exercise in bureaucracy.
Giving physicians autonomy, paid time, and the support they need to create systems that deliver the best patient care possible improves not only the work physicians do, but the lives they lead.
Lara Goitein, M.D., is a pulmonary and critical care physician at Christus St. Vincent Regional Medical Center in Santa Fe, N.M., where she is also the founding medical director of the clinician-directed performance improvement initiative and president-elect of the medical staff.