My struggles with improving quality and clinical outcomes in Interventional Cardiology Department in a large tertiary care hospital!
Leading changes within a cardiovascular service line at a hospital
I work at a large Non academic hospital which is a part of 15 hospital health system. I was hired as the Director of Interventional Cardiology and Cardiac cath lab by the CEO with the sole purpose of reviewing quality data, national metrics and improve it to meet or exceed national standards. We were at the bottom 25 th percentile in terms of mortality, complications and need for urgent repeat procedures in the management of coronary artery disease with percutaneous coronary interventions. Our hospital has a mix of employed cardiologists (50%) and private cardiologists mainly solo practitioners and small groups of 2 and 3 cardiologists. Many have them have been there for > 15 years and hold important administrative positions in the hospital which are elected positions by medical staff (not appointed by the administration). They control the medical staff services, credentialing committees and medical council of the hospital where these issues needs to be addressed. I reviewed the quality data and implemented several changes in how we function and who are qualified to do certain high end procedures and established a monthly conference to review cases to discuss how we can approach these cases better. It has been met with stiff resistance from other cardiologists as many of them are not trained enough or have the necessary skills but do not want to refer patients to competent individuals who can do these procedures with high quality. The CEO who hired me left unexpectedly. The new CEO though sharing the same vision wants no conflict and wants a certain period of status quo. I have had many discussions with the senior administration of the hospital regarding these issues. Our compensation model currently is RVU (productivity based) and this encourages a lot of inter physician competition and not a collaborative environment working towards a common goal. I have no control over these nor does my position have the authority to change any of these. Implementation of many of the suggested changes though agreed upon have not happened as I have no authority to enforce them. I am at a point of considering resignation from my position as I have not been able to influence this process and have sustained quite a bit of negative publicity from the cardiologists threatened by these proposed changes.
This is a more often seen problem that comes with a system that works with mostly individual medical specialists in a financially competitive environment where there’s no accepted leadership. From the outside, this is a clearly unacceptable system where quality clearly is not on the top of everybody’s list, unfortunately. Having said this, I realize this is a very common system that’s basically unbeatable unless a clear hierarchy comes in place. To be honest, I guess this problem is unsolvable for you in it’s current form as “your CEO” has left, and proceeding will get you a lot of extra enemies without a reasonable chance of succeeding. If possible, it’s probably better to get back into practice and set other goals for yourself, or find a similar job within a more hierarchic system. Sorry to be so negative, really don’t think you’ll find satisfaction in this way.
Never give up! You know that you are right: If there is a care-system in wich quality is not on top of the list, than there is a problem. The fact that many of the specialist are not trained enough or have the necessary skills and not want to refer patients to competent individuals is, to put it mildly, a screwed up system.
But what I understand is that you control the data and you can point and give transparency about the differences in group- or individual quality, productionlevel and give openness about patient-, colleagues- supporting personel- satisfaction. With these figures and clarity about the consequences, I as a physician would consider it a unsustainable system and would be open for at least a discussion about it.
You will make enemies but also a lot of friends that have the same intentions and goals as you have
Although I’m bare-handed, I agree with personal gloves. Since you cannot change the compensation model and since it is impossible to create a sense of urgency with a CEO who wants to avoid conflicts, chances are low you can change things. You could hope for some sudden external financial or regulatory pressure to help you, but without this help I think it’s an impossible task.
Situation does not seem to have an immediate resolution. I think the proven tactics of unblinding outcome data to drive behavior (and outcomes) as well as aligning incentives (pay for quality outcomes) could be work if you could get leadership buy in (like maybe from a chief quality officer). you have to be concerned about your own wellness as you decide if you’re able to stay in your current role.
Does your organization have a board of directors or other parent organization that you can appeal to? It may be risky, but it seems that otherwise it will be very difficult for you to continue to lead within the organization.
Unfortunately, until you can significantly impact the current compensation model to start the shift from productivity to include outcomes-based incentives; you will not be able to see a positive effect on outcomes. There is no dis-incentive for poor outcomes in the current model, so providers will never focus on anything other than volume. The key is to start looking at alternative compensation models that will continue to provide financial incentives for productivity, but also for improved patient outcomes.