Episode 10: Doctors Evaluating Doctors

Can improving the way physicians provide feedback to their peer physicians make care safer? How can providers ensure that the right people, policies, and procedures are in place to effectively act on physician performance data? Join host Karen Wolk Feinstein and internist and professor Dr. Thomas Gallagher of the Departments of Medicine and Bioethics and Humanities and associate chair for Patient Care Quality, Safety, and Value at the University of Washington, and pediatrics professor Dr. Gerald Hickson, chair of Medical Education and Administration and founding director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center, as they discuss the concept of physician peer review and how to increase accuracy of and accountability for performance data to reduce medical error.

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Episode Transcript

[00:00:00] Gerald Hickson: All of us who engage in professional practice should have a lifelong commitment to improving our performance. And if peer review is done right, it will support it…

[00:00:15] Thomas Gallagher: The profession itself is best suited to define what do we mean by health care quality and clinician competence, and to assess are those standards being met?…

[00:00:30] Gerald Hickson: The challenge is we have not built strong enough cultures where team members are consistently willing to speak up. We talk about it. Well, we got to do it…

[00:00:44] Thomas Gallagher: Physicians think of themselves as highly data-driven, but when it comes to data about their own performance, they kind of freak out a little…

[00:00:53] Karen Wolk Feinstein: Welcome back to Up Next for Patient Safety, where we envision a world where medical errors, adverse events, and preventable harms are avoided and where we examine the most promising paths to prevent these tragedies before they occur. I’m your host, Karen Feinstein, CEO, and president of the Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative, which is a multi-stakeholder quality collaborative. We’ve been working to reduce medical error for over 20 years, mostly unsuccessfully, but we can’t give up because there’s too much at stake. And that is the loss of approximately 250,000 lives a year and long-term injuries for many more.

Today we are joined by two esteemed guests who will lead us in a conversation on the human context for medical error and how we can improve our system’s ability to evaluate and act on physician performance data.

Dr. Thomas Gallagher is a general internist who is professor in the department of medicine at the University of Washington, where he is associate chair for patient care, quality, safety, and value. He’s also a professor in the department of bioethics and humanities. He is also executive director of the Collaborative for Accountability and Improvement, an organization dedicated to advancing the spread of communication and resolution programs. Dr. Gallagher’s research addresses the interfaces between healthcare equity, communication and transparency. He’s been instrumental in using adverse events as a learning opportunity to improve clinical practice.

In 2018, Dr. Gallagher was a recipient of the John M. Eisenberg Patient Safety and Quality Award for his work to improve transparency and disclosure of injury to patients who’ve been harmed during their medical treatment. He participated in creating a toolkit to help organizations develop communication and resolution programs. And he served on the National Academy of Medicine’s committee to improve diagnosis and health care. His work includes research on how state and federal policy influence disclosure and how disclose your training programs overcome barriers to disclosure.

Our other guest, Dr. Gerald Hickson is the Joseph C. Ross chair of medical administration, professor of pediatrics and founding director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center. Dr. Hickson joined the department of pediatrics in 1982 and served six years as vice chair and chief of pediatric outpatient services. In 2003, Dr. Hickson was appointed associate dean for clinical affairs. In 2013, he was appointed senior vice president of quality safety and risk prevention. Since 1990, Dr. Hickson’s research has focused on why families choose to file suit, why certain physicians attract a disproportionate share of claims, and how do I identify and intervene with high-risk clinicians?

His work has resulted in over 200 peer review articles, chapters, webinars, and educational initiatives to promote disclosure of medical errors and change behaviors that undermine a culture of safety. His center at Vanderbilt developed a patient advocacy reporting system (PARS) and the co-worker observation reporting system (CORS) programs that use unsolicited patient complaints and co-worker observations as the basis for tiered interventions on high-risk clinicians. These programs have been implemented in over 200 hospitals and health systems in the U.S. And Australia. Dr. Hickson has served as the chair of the board for the National Patient Safety Foundation and is currently vice chair of the board of the Institute for Healthcare Improvement.

Welcome Dr. Gallagher and Dr. Hickson. I will not say the Tom and Gerry show because there may be people out there who aren’t as familiar with the cartoon, but we are absolutely delighted to have you here. Before we dive into the questions for today’s episode, I’m going to just provide a little background information. Today we’re going to consider how innovations in peer review can make healthcare safer. For those unfamiliar, peer review is the process of physicians reviewing the performance of other physicians.

Today though, we’re going to explore opportunities for larger inter-professional teams to engage in the peer review process. We’ll also discuss the potential of technology to supplement the peer review process. Today, machine-based algorithms might provide useful, helpful, unbiased, and objective safety and quality. Finally, and this is key, we will discuss how to ensure that the right people, policies, and procedures are in place to make sure that systems effectively act on their performance data. So now we begin finally with my first question. Let me ask you both. What is the connection between quality, safety and professional behavior? And please tell us, how do you define professionalism and how it links to medical team performance? Tom, we’ll begin with you and then go to Gerry.

[00:06:07] Thomas Gallagher: Thank you so much, Karen, for the opportunity to chat with you today. When we use the term professionalism, it refers to a set of values, commitments and behaviors that undergird medicine’s contract with society to act in the best interest of patients by providing them with the highest quality care. Achieving safe and highly reliable healthcare hinges on striking just the right balance between a focus on systems and an understanding of the responsibilities of all the individual health professionals who make up the clinical team.

Fortunately, the field of patient safety has appropriately stressed the importance of abandoning of moving away from its historical focus on clinicians who were thought to be in quotes, “bad apples,” but there is good reason to believe the pendulum has swung a bit too far. With insufficient attention being paid to the professional behaviors that we expect every single clinical team member to exhibit coupled with ways to promote accountability around those expectations. Unfortunately, if you focus just on systems, you’re missing a really important piece of the puzzle.

So ensuring the competence of healthcare professionals is one key element of professionalism, other key elements as articulated by Dr. Hickson and his group at Vanderbilt include clear and effective communication, respect for others, effective teamwork, and importantly self-reflection. I would love it, for example, if clinicians, when they were walking into their workplace, periodically paused and considered, “am I making it easier or a harder for others to perform their work?”

[00:08:13] Karen Wolk Feinstein: Thank you so much. And you know, you remind us all, Tom, that systems don’t deliver care, people do. It is the sum of its parts. So Gerry, do you have a response also?

[00:08:26] Gerald Hickson: Karen, I also very much appreciate the choice of this topic and that we will encourage people to pause and reflect about how we build right systems and accountable humans, because there is this partnership that I think is so important. A health system should pledge to the individuals who walk in the door, that we’re going to do everything we can to make it as easy as possible for our medical team members to do the right thing. That’s building right systems. Then the professionals who walk in the door and need to make an equal commitment to the patients that are served, that we’re going to take full advantage of those systems. We are going to respect other humans. We are going to respect best practices. That to me is what’s key.

And Karen, one quick example, let’s consider for a moment that you and I are members of a surgical team. I’m the surgeon and I routinely model disrespect toward you, and I do that when I walk in today… what does that do to your ability to do your job? What does that do to your focus? Are you focused on me and when I’m going to explode, or do you focus on your task and duty? And over the past five years, a number of research teams have identified very clearly that when I model disrespect, I reduce your willingness to speak up in the moment, I reduce your willingness to ask for help.

And if we’re a team, which we are, I need your help, I don’t always behave as though I need it. So our research team has looked and shown that if you’re a patient and you come and see me as someone you don’t know, but I am disrespectful by nature, you have a 25% increase risk of having surgical site infections, or having to be readmitted to an ICU, to have to be re-intubated, to have a stroke, death, sepsis… every single measure of performance declines when we exist in this environment where we’re not respectful of each other. So yes, we fix our systems, but let’s turn a little bit more attention to how we behave within the time we’re together.

[00:10:34] Karen Wolk Feinstein: That is so interesting as a patient. I have no way of judging that the clinical competence of an individual physician or a team. So I kind of go intuitively on how they… how they relate to each other, how they relate to me. Do I feel good in this environment? But now you’re telling me that that sort of intuition might have some validity. That that intuition may be guiding me to the selection of a team that is well-functioning. You both mentioned professional accountability, self and group-regulation… just connect those to the process of peer review.

[00:11:12] Thomas Gallagher: It was clear to me, Karen, on the first day of medical school, that I was entering a profession and that a hallmark of being a professional is self-regulation. And that’s in part because of what you just said, which is, unlike commercial – sort of ordinary interactions – patients have a very hard time judging the quality of health care they’re getting and the competence of their providers. So this imperative of self-regulation reflects the fact that the profession itself is best suited to define what do we mean by health care quality and clinician competence, and to assess are those standards being met? And every single healthcare professional has a role to play in this process, which is why we use the term peer review. But unfortunately, far too often, the focus is on the review element without an appropriate link to feedback and to accountability.

[00:12:18] Karen Wolk Feinstein: Gerry, do you want to make a comment on that?

[00:12:21] Gerald Hickson: You know, Karen, I go back to this notion that feedback is key, and I’m a pediatrician so I will continue to go back that we provide feedback early and often in respect. I love Justice Brandeis’ writings, and, you know, he wrote a lot about professionalism and he continued to emphasize the fact that there is this obligation to both self-reflection… the question Tom asked early that when I walk in the room, do I periodically say, “do I make it easier or harder for Karen to do her job?” But the other responsibility that we’ve been very hesitant about and why we need focus and research is on the group-regulation, which peer review can help if done right. Now, you know, just a couple of other comments based upon Tom’s statements.

You know, peer review is an obligation. It’s an obligation to hold one another to ethical standards of the profession. Just scrutinize each other’s performance and provide feedback again, back to that issue of feedback, with the goal of making each other better. All of us who engage in professional practice should have a lifelong commitment to improving our performance. And if peer review is done right, it will support it. Now, you know, the other thing that I think is really important is that peer review requires this balance where we recognize the professional’s ability and right for medical judgment. But there’s this obligation that goes with medical judgment, that we are going to commit to reliable, safe, equitable care for everybody.

This process of peer review is too often just people checking a box and saying we’ve had a meeting. And so the question becomes, is it who we are or is it who we say we are? I want it to be who we are.

[00:14:19] Karen Wolk Feinstein: Thank you, and professionalism, listening to you, is so much more than just mastery of skill. And as a pediatrician, I know how important you are in the lives of us parents, that we would have a much more difficult time parenting securely if we didn’t have a good relationship with our pediatrician, well beyond just giving vaccinations on time. You also, which is interesting, pediatricians you have your own patient safety organization, which I think is terrific, but I would also say, the affection that people feel, the confidence in their pediatrician… two of the largest funerals ever held in Pittsburgh were for two beloved pediatricians. So the impact on our lives and our children’s lives is really incredible.

So consider me a bit of a skeptic, having chaired credentialing for far too long in a health system, how effective is peer review? How can health systems support and assure that high expectations for health professionals? I’m going to turn this one over to you, Gerry,

[00:15:28] Gerald Hickson: You know, Karen, I share a little bit of your characteristics about being a skeptic and I’m a “trust but verify” sort of individual. Now that said, I feel very strongly that professionalism is an underpinning of way more than just professional self and group regulation. It’s essential to a health system’s pursuit of high reliability and safety. You cannot have a health system that’s safe without real, honest, robust peer review that involves all professionals.

So I think we have to understand that where we talk about peers supporting each other, that process supports the hospital, the health system as well. Now the second thing, you know, I want to make the point that the right infrastructure, the right people, the right processes, the right systems can be really effective and there’s some great examples. Our team has done some great work identifying high-risk clinicians and sending peers to their space, to share with them that they have opportunities to improve. And the great news is that most will, if they get that direct feedback, but you can’t get peers to engage in that work unless they’re given quality data. They know somebody’s got their back because it’s not always an easy task.

So one of the things that I want to emphasize to individuals who will listen to this session is the fact that there’s got to be this full partnership with all the C’s, the CEOs, the CMOs, the CNOs, the CFOs, no matter how big or little that a system may be. They have to understand that they’re stakeholders in that because they’ve got to help with building the infrastructure that often is here in bits and pieces, but often siloed and not brought together in an effective way. And I want to say just a word or two, about some of the essential elements of infrastructure, because you just can’t do peer review on personal courage.

I can look at my own performance. I may look at yours, but if I’m talking about a thousand or two thousand professionals, now we’ve got to have a plan and it has to be an effective plan. And our research team at Vandy has learned the hard way over the past twenty-five years, how to build and pull together elements. Just a few of those essential elements… when I think about people – I’m going to go back to this several times – It is about leaders that are committed to being fair and equitable to all and will not blink because any single individual has special status. It means having a peer champion who will be enthusiastic for the program to be sure that it’s put together.

It has all the elements that the data are delivered in a timely fashion. It means that it’s supported by a team that has costs. And that’s actually how, you know whether the CEO of the system is really committed or not, because the question is, will they support infrastructure development? One of the things that we’ve learned is that it’s gotta be linked to your core values and those core values have been created by the team. They didn’t come down from on high. They were built collaboratively and are a part of my performance evaluation as an example. And it means that those values then link to how we provide feedback. And so one last thing I’ll say is that organizations have got to have very defined ways, that if I’m going to be evaluating your performance, Karen, that you know how I’m going to assess it. That when you’re doing awesome, you’ll know you’re doing awesome.

When you have an opportunity or you may stub your toe, you will be provided in a tiered intervention process, a right measured non-judgmental statement to give you an opportunity to pause and reflect. And gosh, if you began to accumulate data that suggests a pattern of not awesome performance that we give you an opportunity and give you if there’s national comparison data, so you will believe as a pediatrician “I really am not handling this as well as my colleagues.” And then there must be skill and ability to take care of those few that are unwilling or unable to respond to peer feedback. Provide them the support they need, or to help them at some point, understand that they may not be a good fit for that organization. All of that is required and it can’t be done on an ad-hoc basis. It has to be planned and run predictably for every team member fairly.

[00:20:29] Karen Wolk Feinstein: You suggest to me how critical the role of the top leadership is in a health system, that they are by their decision-making and their behavior, they’re suggesting what the values of the system are. And it goes all the way down, down to the behavior of individuals at the front line. But you know that leadership by its own behavior suggests what the values of the system are. And I’m hearing that.

[00:20:58] Gerald Hickson: Karen, I would say that those values need to be on the wall. They need to be part of the introduction every time the CEO speaks, linking those values back to what we’re asking people to do. That’s been so important during COVID and those organizations that have repeatedly taken people back to their north stars have done very well.

[00:21:25] Karen Wolk Feinstein: And on the other hand, what is said, and what is done are two different things. And you can undo a lot of good by behaviors that suggest they’re contrary to the values that everyone has put up on the wall. So thank you. What are the greatest challenges that professional hospitals and, and both of you yourselves face in pursuing peer review?

[00:21:51] Thomas Gallagher: I’m extremely fortunate to come from a family of physicians. My grandfather was a solo practice pediatrician in downtown Los Angeles. He actually was my pediatrician for a little while until my mom thought maybe that wasn’t such a good arrangement. My dad was a primary care geriatrician in Los Angeles with his office next to the post office. And it was clear to me that both of them sort of deeply treasured their relationships with their patients, but they also cared enormously about their relationships with their colleagues. When my dad opened his medical practice, I was in preschool and believe it or not, he had an open house. Not for prospective patients, but for all of his colleagues in town. And my two sisters and I had to get dressed up and walk around with little plates of hors d’oeuvres so my dad could sort of develop effective relationships with the rest of the physicians in the community.

Can you imagine a physician starting out in practice that way nowadays? It actually reflects this historical trend… actually, if you go back and look at the Hippocratic oath, the first sort of third of the oath is not about our relationship with patients. It’s about our relationship and having respect for our colleagues, which is a good thing. But I would argue that the profession has taken that sort of respect a little bit too far, almost to the point of excessive deference. And so when you take that deference to colleagues and couple it with our normal human instinct to want to avoid uncomfortable interactions, it makes it much harder for us to speak up and as a group to hold each other accountable.

There are clearly some organizations that have excelled in the area of professionalism and peer review, but I would say more commonly, organizations haven’t put the people, the processes, the systems in place that Gerry was mentioning, and it’s those systems that allow us to overcome these natural human tendencies that we have to want to sort of stand back from this process. I’ve really been fascinated with the area of physician engagement in peer review and it’s an especial challenge because of those natural human emotions. When we need to sort of consider the quality of care our colleagues are providing and maybe even speak up and say, “Gerry, can you tell me a little bit more about why you ordered that particular antibiotic for Mrs. Smith?”

Our tendency to shy away leads us to think, “well, maybe somebody else will take care of peer review. Maybe peer review is somebody else’s problems. I’m not on the quality committee. I’m not the CMO.” It’s a little bit like in school where if the principal knew your name, it felt like it probably was a bad thing. You wanted to fly under the radar and unfortunately that’s exactly the opposite of what we want to happen with peer review. We want every single provider to sort of recognize this is a core element of my responsibilities as a professionalism and to be thinking, “well, what, what role do I play – rather than looking away – what role do I play in effective peer review?”

[00:25:44] Karen Wolk Feinstein: Excellent, thank you. And Gerry, do you want to comment on that?

[00:25:48] Gerald Hickson: I just want to affirm what Tom has said. You have to have the infrastructure. The infrastructure, its presence is actually a litmus test of whether the organization is really committed or not. And then the second thing, this fits in now back to the notion of a culture of safety. So we talk about performance issues. We talk about people being willing to speak to each other about antibiotic choice, or is this appropriate surgery? Those things are very important. The other side of the equation is when disturbances in the force occur. I use that term all the time. When I have been disrespectful to you, Karen, as a fellow team member or to a patient, will someone speak up?

When our center works with other institutions, one of the first questions we ask them and we ask people in the rank and file, if this disturbance in the force would occur, what’s likely to happen? Do people look the other way, do a few individuals attempt to address in the moment? Or if, for whatever reason and there are situations in which it’s not appropriate to address in the moment, they go back and have a safety reporting system. But if you have a safety reporting system, do people have confidence that the organization is so committed that that disturbance in the force will be reviewed quickly?

5% of those disturbances in the force are things that require mandated investigation, physical contact, sexual boundary violations, coming to work impaired with drug and alcohol, assertions of discrimination. 95% of the disturbances in the force need to be dealt with, but we find just simply need to be dealt with by a peer who knocks on a door in three minutes, shares with you a disturbance in the force, simply asking you to reflect on that experience and what you might do next time and affirms that you’re an important member of the team and leaves it to you to solve the problem. That approach is so effective, but the question is, are organizations committed? Do they have the infrastructure? The peers will respond when given good data and know this is a reliable process. And the CEO will not treat some individuals differently because they have special value.

So going back to Tom’s comments, whether it’s antibiotic prescribing, it’s my respectful behavior to you, we all need feedback. We shouldn’t run from it, but it is not something that medicine has done consistently well, but we’re working on it.

[00:28:28] Karen Wolk Feinstein: You’re also suggesting there’s a formal infrastructure and an informal. A set of accepted behaviors that also guide the team.

[00:28:40] Gerald Hickson: So Karen, it’s exactly right and I see so often when a health system is going to learn high reliability. And we’re going to bring in widespread training and we’re going to train everybody in higher reliability because we are now committed to safety, which means that if a surgeon walks into the OR and says, “I’m not following this time-out process, you guys just call me when you’re ready.” The question is what is going to happen? And so many of the team members will take the leader promise that we’re going to high reliability. They’ll put that promise into escrow and they’ll wait until the next time they’re in that same OR and they see whether or not anything different happens.

That’s how we build sustainability because we take each disturbance in the force and we deal with it respectfully, non-embarrassing in one at a time, and people do improve. That’s the good news. And only 3% of nurses, advanced practice professionals, and physicians wind up with more than their fair share of these disturbances but even then, we’ve got to play it.

[00:29:50] Karen Wolk Feinstein: I love it, it also explains to me one of my favorite moments, my doctor, who was chair of internal medicine, said that I had shingles. So I didn’t need the shingles shot. And his nurse spoke up and she said, “no, you should get the shingles shot.” And my doctor respectfully said, “okay, prepare the shot.” Now you’re going to laugh, why out of all the encounters over 25 years, that stands out. I love the respect that my doctor showed toward his nurse. I felt like I was in good hands. So people often misinterpret what makes a patient feel confident.

So aside from infrastructure, we now have a lot of rich data in our electronic health records. So can we identify physicians who may be getting worse outcomes or are practicing outside of standard procedures? Can we use these physician performance data to support peer review? Are physicians willing to reflect on their individual performance? For both of you, what about using data in the electronic health record as well?

[00:30:57] Gerald Hickson: So Karen, peer review requires good data, not perfect data, good data. And you know, our experience is that professionals, they walk in to medical school, they continue through their career up until the time of retirement. And, you know, they want to know how they’re doing and they want to know how my performance compares with Tom’s and others. That’s a part of our nature. And most of us want to be at the 90th percentile or higher in terms of getting our patients vaccinated against shingles. I mean, those things are really important, but the challenge is it’s how you produce good data, and data that is understood and trusted by the team.

And to do that, again goes back to that leadership commitment that we really want to give our team members an opportunity to kick the tires. We have just finished a study of 12 years in duration in an unnamed medical center where I work. And during that time we discovered several years ago that it appeared that our performance in colorectal surgery was gosh awful, but all of our surgeons were certain, these numbers were wrong. Our patients are sicker. They are far more complex. And so this discussion continued and, you know, as a pediatrician, I don’t know anything about doing a surgery, thank goodness, but I did know what we could do. Let’s get all of our colleagues to get into the weeds about the data. So those surgeons reviewed 450 cases that were identified as having infections.

And we said, “you go through them in detail. Don’t tell me they’re not legitimate. Don’t tell me they’re legitimate until you get into the weeds.” Well, they discovered 10% of them were misclassified and they had focused on the 10%, but when they sat down as a group and recognize that 90% of these infections were in fact real, they recognize we’ve got a problem and let’s get to work. So what I want to emphasize is that so much of the pushback that physicians give about data is because they’ve been given data that’s not trustworthy. And my notion is let’s not fight about it. Let’s get in the weeds. And so just a couple of principles that I would suggest that we need to think about.

I think number one, professionals need to be engaged at the case level. If we’re going to use a measure to assess your performance and how I’m going to evaluate you as a member of the team. So Karen, you’re going to want to know in advance and you’re going to want your questions answered. That’s fair. Number two, a second thing, I want to be sure that you’ve got an easy-to-use dashboard that’s populated with measures. You have had a role in selecting professionalism measures, citizenship measures, quality measures with national comparison data, that’s really important. And then, you know, the other thing that I feel very strongly about, we have to keep constant pressure on the payers. So often they revert to claims data without really understanding the performance data themselves and data are often delivered after the performance timeframe.

So the notion is let’s use common sense principles. Let’s have a professional team, actively involved, reviewing, vetting every new metric we’re going to use. And let’s be sure that if the CEO and the CMO and the CNO choose a set of metrics that we’re going to pursue, that we’re also providing the right resources and intentionally design systems to allow those professionals to get the work done right. Those are a few comments that I have. It’s about creating right partnership.

[00:35:17] Karen Wolk Feinstein: And Tom, you get to answer two questions. If you choose one, greatest challenges and secondly, how do we get physicians more comfortable with the data, but also the data accurate enough that they have confidence? A dual challenge.

[00:35:35] Thomas Gallagher: Well, I think both of those questions are related, Karen. I think the challenge that fascinates me is this issue of physician engagement. And it’s particularly interesting to sort of see physicians’ mixed emotions when it comes to data. Physicians think of themselves as highly data-driven, but when it comes to data about their own performance, they kind of freak out a little bit. We did one research study where the vast majority of physicians said, “I want better data about my performance.” In that same study, almost all of them said “my performance is above average,” the Lake Wobegon effect, right. We all think we’re doing better than the average.

And when it comes down to actually looking at their own data, either they don’t get enough… I have never gotten any systematic data on my diagnostic performance, zero. The only opportunity I have to learn about opportunities for diagnostic improvement is when I look in the chart and realize a patient’s gone to see a physician and I was not on the right path diagnostically, no feedback. The challenge though, is getting physicians to the point where they trust the data. And I really liked the approach that Gerry has outlined in terms of creating a shared responsibility and accountability for what are those measures, and then building trust so that physicians don’t have that immediate reaction of “your data’s not right, that doesn’t apply to me.”

[00:37:14] Karen Wolk Feinstein: The other comments I’ve had – I sort of collect them related to data, but I also – we had a surgical team that was getting a very high seemingly infection rate and they said, “no, no, we don’t have a high infection rate. We just have more false positives than other teams.” So that’s on my best… yeah, I guess pathology has it in for your team.

So let’s look at health systems and maybe health plans, what incentives do they have to identify and assist physician outliers? In today’s system, what would motivate them to get engaged in real-time identification and intervention, particularly for physician outliers, not in a good way who are not getting the best outcomes or don’t have the best safety and quality data?

[00:38:09] Gerald Hickson: So Karen, as we move more and more to the notion of population health, they’re going to be incentives that we want to look at how medicine is doing. From certainly we’re going to continue to look at how many avoidable infections there are and what can be done, but now we’re looking at bigger issues of wellness. And as we begin to tie expenditures to wellness and to avoidable outcomes, there will be more interest in attention by payers to get that right. And that’s a good thing. And so I think those incentives are there. The challenge is that there’s great variability among the plans.

There are some that are farther down this approach and others, there are others that are late to this process and may not really understand how to do it and talk about having quality metrics, but they really are not real. It is, gosh, we’ll put this, we’ll say we have it, but do we really have it? And this is why I go back to the question I like to ask the plans. “Do you understand your data? Would you be willing to take your data and sit with me with a pediatrician and a practice in a community in Tennessee and suggest to them that they’re not practicing correctly?” Would that assertion stand to appropriate challenge?

Those are the things that are needed, and we are not quite there yet. Plans at this point may seek to incent people to join their plans because they’re in growth mode now. Are they to a point where they’re willing to say, “Karen, your practice, your prescribing, your admissions, these things are not aligned with what we believe are best practices, we want to provide you these data.” But there is that tiered step-wise approach to whether or not you’re going to be a good plan member in the future. And then a willingness to actually say, “Karen, our practices are just not aligned close enough.” those things sound nice. We have to get there.

But I’m going to continue to come back that I see a much more effective way to do that is to have the medical group, that health system doing its peer review with its prioritized measures so that people understand the logic. They understand that this has been identified by people I practice with. And I know that one of them may be knocking on the door, but the purpose of their knocking on the door is to encourage me to improve, not to kick me out of a practice. Those are some random thoughts…. we’re just not quite there yet, but we have to keep up the encouragement.

[00:41:08] Karen Wolk Feinstein: I’m also intrigued with the idea of whether plans should be sharing some of that information with their customers, with the employer groups, and the employees. I know that’s wildly controversial, but I often say, “why don’t you let me know?” Now that we have integrated systems, I think it’s gotten even more complicated. The motivations of plans once they’re embedded in a system that also has a need to fill their beds. I think things get more complicated, maybe more value-based payment and a more honest reckoning as to outcomes and adverse events will help us as we move forward. And the centers of excellence.

So for both of you, when the media bring our attention to cases of egregious physician behavior, layman, people like me, wonder if health systems or peers within the different medical specialties where they practice could have seen warning signs before patients suffered. And I’m wondering how could high-functioning peer review programs interface effectively with physicians day-to-day when concerns about their work surfaces? It’s impossible even to provide real-time customized learning opportunities for physicians who are identified as being out of the bounds of accepted guideline behavior.

[00:42:37] Gerald Hickson: You know, Karen, it’s really a key question and we have focused on building systems. But we have to get to the human side of this equation. We recognize that the vast majority of professionals are professional. And as our research has shown, there’s a very small subset of individuals that do not perform professionally, but if you give them feedback better than 90% of them will respond. But then there are these egregious cases, either care that’s egregious or behaviors of one human directed toward others, that just can’t be acceptable. I’m going to go back to the fundamentals and say the challenge is, we have not built strong enough cultures where team members are consistently willing to speak up. We talk about it, but we got to do it. And it’s important to recognize, let’s just start at the beginning, to acknowledge that sometimes team members are actually discouraged to speak up because someone in a leadership position. And for whatever reason, has a commitment to protecting a high-risk clinician. We’ve seen that in individuals who have extra ordinary influence and people look the other way until something disastrous becomes apparent.

Now, the challenge is the good news, the bad news is that sometimes those egregious events when they become public, will push leadership to do something and that’s actually what happened at Vanderbilt back in the early nineties, I got into this work because I got invited to a really fancy dinner one night by the vice chancellor and that just didn’t happen. And I was a junior faculty member and I did not miss a free meal and an adult beverage. I mean, it was just awesome and we really didn’t know why we were there. We had this meal and then at the right point, he moved all of the staff out of the room. Locked the door and then described an event that had occurred at Vanderbilt, nationally recognized faculty member who was in clinical care, an error that had a huge impact on a patient and a family, a nursing team that kept trying to get something done.

And at that particular point, Dr. Robinson stopped and said, “we all saw this coming. We all saw this coming, shame on us. And the reason I brought you together is that I’m going to expect this group to develop a plan. And I’m going to lock this door and not let anyone out until we commit that we are going to identify challenges as early as possible and create a way to provide feedback and to prevent these when possible, and it’s not always possible.” Now by chance, I was working with an economist at Vanderbilt, Frank Sloan, and we were really interested at that point in a phenomenon that Frank had reported that somewhere between 2 to 8% of physicians by discipline account for approaching 80% of malpractice claims and payouts, opposed to the standard myth that I’m a neurosurgeon and we all get sued, it’s not true. 35 to 40% of neurosurgeons never get sued, but 8% get way more than their fair share.

And so, as a pediatrician, I was interested in what might be contributing and what we identified was it goes back to the issue of respect. These individuals that are at high risk had difficulty working collaboratively with others, either patients and families or staff. And so we stumbled into the fact that those unsolicited observations, those safety reports submitted by fellow team members were sufficient to reliably identify those at-risk individuals. And so we created the two tools, PARS and CORS, and we now have spread their use. And we now have overseen and tracked better than a hundred thousand physician’s behavior identifying 3000 of them, that model patterns of behavior that make them at high-risk.

So as a pediatrician, you know, Karen, what I thought about, gosh, if I can reliably identify these docs that have way more than their malpractice claims risk and those patients get more surgical infections, more medical complications… we can do the math, but as our risk manager walked into my office unannounced one day, he said, “Hickson you’re doing all this research, but can we do anything? Can we solve this challenge?” So we went to work, trying to figure out a way to provide feedback to those high-risk clinicians in a way that would maximize the chance that they would pause and reflect and self-regulate as professionals.

And that’s where we developed a tiered intervention method beginning with just what we call a cup of coffee, escalating to make you aware, Karen, that for some reason – listen to the passive language – your performance data appears to indicate you’re at risk. Now it isn’t just risk for malpractice claims. We’ve looked at antibiotic prescribing, hand-washing, surgical side effect… it doesn’t matter what it is. 3% just have difficulty performing. So we provide feedback and lo and behold, what do you think we found? Humans will respond when that message is first delivered by a peer, not a leader. You save the leader until that individual has modeled the fact that they are unable or unwilling to respond. And the great news is that of the small group of non-responders, if they are provided a directed intervention under authority, their authority figure, whoever they may be in that health system has now said, “Karen we’ve served coffee. Karen, we made you aware for some reason, these behaviors, this performance continues. At this point, we must be directive and here is the plan that we are going to expect you to follow and failure to follow this plan may – and the keyword is may – may lead us to take additional actions.”

There’s nothing more powerful than the uncertainty associated with may. You don’t put a line in the sand. You give them the knowledge that there may be consequences, but if there are consequences, Karen, it’s your doing. And we know that better than 60% of those individuals that go to that level will respond and stay respond. But again, it requires core values, an infrastructure, leaders who won’t blink, and peers who will knock in the door on the door and start this process, but it will work, but it’s taken us 25 years to figure that out. We’re slow learners.

[00:49:40] Karen Wolk Feinstein: But it sounds powerful. So my question to Tom is, many physicians know a colleague to whom they would not send a family member or a friend and maybe with whom they should be having the conversations that Gerry referred to. What holds them back? What, why do you think that people are very uncomfortable mirroring the behaviors that Gerry just mentioned? That if you could give me a quick, what is the role of state licensing boards in dealing with physician outliers, but anyway, what… what holds physicians back?

[00:50:19] Thomas Gallagher: It turns out that it’s not just physicians who are being held back, it’s a natural human tendency that that patients and healthcare professionals have to not speak up when they have concerns. Some of this is they don’t want to be critical of others, they worry about consequences, they worry that they might start a process that somehow gets out of control. One of the most interesting things, we’ve done a lot of research, actually with patients who have observations about something that’s gone wrong in care. Gerry is right that some of them will raise this concern and you can do incredible things with those unsolicited comments, but in our research close to 40% of patients in the hospital think that something serious has gone wrong in their care and about 10% of patients will share their concern with anyone.

Why is that number so low? It’s so low because they worry that if they raise their hand and say, “something’s not right here,” it could have implications for their healthcare. And they’re just not willing to take that chance. So early on, our efforts to try to get people to speak up focused on encouraging just that. Right? There were posters on the wall of a nursing lounge. “Speak up for safety.” Doctors were supposed to wear buttons that said, “asked me if I’ve washed my hands.” The problem with that was that it put the entire burden on the person to speak up and we realized that’s actually the opposite of what ought to happen.

It’s the responsibility of the healthcare organization to create an environment, and Gerry has described that environment beautifully, but to create an environment where it feels safe for a patient, for a clinician to raise their hand and say, “something’s not quite right here.” And to be confident that that concern is going to be acted on appropriately. Now you asked about state medical boards, they’re an important, and I would say underappreciated part of the quality and safety landscape, but they have some challenges. They’re typically complaint-driven, which means they can’t start looking into something until a formal complaint has been filed. But they are independent from the healthcare organization, which means they can conduct an objective investigation. State medical boards are crucial when we think about regulation of the practices of physicians who are in small groups or may not be affiliated with a hospital or a health system.

But the big problem that state medical boards have is that they don’t have the information about the performance of that healthcare professional on the ground that the health systems have. So I would love to see a future where in some respects, state medical boards perform more of an oversight function, making sure that systems have all of the programs that Gerry has described and that they’re being implemented effectively much like the Joint Commission comes in and inspects policies, procedures, those sorts of things, but it’s up to the organization to drive their implementation. But like peer review generally when physicians think, “I hope somebody else takes care of this,” the profession, when it comes to state medical boards has largely just wished they would go away, which is the wrong approach. We need to embrace and partner with them. And together, I think the quality, safety, and peer review programs are much more effective.

[00:54:09] Karen Wolk Feinstein: I’m hoping that the two of you leaders in the field will champion that role for the state licensing boards. I think that would be productive. And Tom I’m still struck with the fact that you don’t get feedback on your diagnostic performance. I mean, I’m still thinking about that. And once I had a recommendation for a very rare sort of complex, still experimental surgery, and I got a call from a nurse at my health plan and the nurse contradicted the doctor. She said, “you should not be getting that surgery.” Now, this only happened once in my life, but I didn’t get the surgery and I didn’t need this surgery. I’ve been just fine, it’s years later, but here’s what worries me. This is what in Lean we call a work around… how many others just follow the advice of that doctor and had that complex surgery still experimental when it wasn’t necessary? It worries me that we don’t often confront the real problem. I’m delighted the nurse called me. I wish I had her name. I thank her all these years later.

Let me just switch gears to something that’s different, I think. I’m now assuming that there are data that indicate that physician age can be a risk factor for performance problems because some healthcare systems have programs to screen physicians once they hit a certain age, I believe it’s 65. Are there other accepted risk factors as well that could be demographic or behavioral? And what have we learned from programs like that that could shed light on peer review overall?

[00:55:45] Thomas Gallagher: Well, I’ll kick this off. So a couple of years ago in 2019, this outstanding group in Canada published a very comprehensive review of the risk and of the supporting factors for physician performance. They found strong evidence in a couple of areas, strong evidence for age, for gender, for exam scores, and for specialty. They described what they call probable risk factors, which where the evidence was present, but was less strong, practice experience, workload, being in solo practice. The problem is for many of those risk factors, the associations are not strong enough to drive policy with one exception and that’s the area of physician age, which has been a particular interest of ours. And there are these programs, which are called late career practitioner programs, LCP programs. It represents in my opinion, a very interesting case study when it comes to the area of peer review, because most other safety conscious industries, screen providers for their ability to perform safely, more frequently, they do that screening more frequently as practitioners age, and there’s clear data that the risk for poor performance increases as physicians get older.

So these late career practitioner programs screened physicians for their physical, their technical, their cognitive performance as they age. And I think screening in this one context makes a lot of sense. For example, the late career practitioner program at Yale a few years ago, reported out their screening experience with physicians over the age of 70, over a three-year period they screened 141 physicians. 13% of them were determined to have cognitive deficits that were likely to impair their ability to practice independently. 13%. And none of those had previously come to the attention of medical leadership, but this is a super tricky area because you’ll have some 75-year-old physicians who are performing just as well as when they were 55.

And you have some 65-year-old physicians who are beginning to struggle. But physicians by-and-large, this notion of late career practitioner programs drives them bananas and they resist it tooth and nail. And I think it’s just more evidence that we have to build that culture that Gerry talked about, where they’re engaged in the process of identifying the measures and have confidence in the process and hopefully that will lead these types of programs to be embraced by physicians over time.

[00:58:41] Gerald Hickson: Karen, I would add a comment here. I agree with the notion of screening, especially with the issues of age, but I’m going to assert that we need to screen every clinician from day one of practice to whenever it becomes decided that I am going to step out of practice, because there are lots of reasons. In our national database working with over a hundred thousand physicians, one of the observations we made from the small subset of individuals that were unable or unwilling to respond to interventions, four of them had evidence of CNS lesions, brain tumors that were affecting their performance. There were a number of individuals, and we published a paper three years ago using natural language processing to look for words and word combinations in unsolicited patient complaints, to identify clinicians that had evidence of early cognitive dysfunction. So we now use that natural language processing to identify those clinicians who are at risk.

And we, to reinforce what Tom just said, are stunned at how often the patients are saying things. But there don’t seem to be… there doesn’t seem to be any recognition by fellow professionals that this individual is in trouble. So you need screening. You need feedback locally, but I would suggest it’s a part of all ages with, as the data supports intensified screening for certain risk groups. The other thing we’ve learned to do now, is to use that natural language processing to identify individuals where there are individual reports or patterns that suggest sexual boundary violations. This is a huge issue of national importance that has not been dealt with well, and yet, in so many cases, the clues are there again if the organization has the people, process, systems and use new technology to identify something that otherwise creates great risks in lots of different ways.

[01:00:50] Karen Wolk Feinstein: I love that comment is as the data suggests. We do have a team here in Pittsburgh, working on identifying outlier physicians and their goal is to see whether outlier behavior leads to better outcomes or worse outcomes. But it’s also, if the algorithm gets developed, maybe a way of identifying physicians that might need some kind of intervention.

So let me finish on what to me is one of the more important questions for me. How can the public, or more importantly, governing boards know if they have a robust peer review program within the hospital or health system, to which they’re connected? If you are both designing the most effective system to ensure that physicians and all health professionals were providing the best care with the best outcomes possible, what would it look like and how can I, as a board member, know that my system has a very strong peer review program? Tom, do you want to go first?

[01:01:53] Thomas Gallagher: Yeah, so I work closely with a wonderful group of patient advocates who are deeply committed to advancing quality and safety. When you ask them about the peer review process, not only are they skeptical, Karen, as you mentioned very early on, they feel like this is a process that’s shrouded in secrecy and sort of reeks of self-protection. And some aspects of peer review need to be confidential to really drive quality and safety. But when it comes to the public, I think we’re doing ourselves a disservice by not being more open about how peer review works, describing the process. I think if the patient advocates heard about the multi-element program that Vanderbilt has developed, I think they’d be deeply impressed.

But we sort of think that self-regulation means we sort of do this all in private. And I think that has diminished our trust in the effectiveness of this program. So I would love to see a world where the norm is the type of program that Gerry has described, where we’ve created an environment where we routinely and respectfully provide our colleagues with feedback on performance and then act on performance data in a way that makes it normalized. That makes it, this is just a part of what it is to be a healthcare professional.

[01:03:31] Gerald Hickson: Karen I’d like to follow up just a brief comment. You know, it’s been an interesting stepwise approach to culture change that began at Vanderbilt in the early nineties when we recognized and had a courageous leader who said, “not again,” and without that launch and the tenacity that has been brought to this… because it is not easy to get people, to be comfortable with change, to begin to give them feedback in a dashboard. The first question is who else gets to see this? So those questions need to be answered and it needs to be respected. And they need to know and understand all of us as professionals that we do this to elevate everyone’s game, not for someone’s detriment. So doing that is really important.

I want to say a word or two about board participation, because I feel very strongly about this. And as you know, from my resume, I’m on a bunch of boards and I’ve learned a lot because when I walked into the first board experience, I sorta thought it was an honor. It was not an honor, it turned out to be a big responsibility and duty that I didn’t fully understand or expect. So a few things that I think are really important is that, you know, the board needs to be in a position to ask regularly, “is our health system safe for patients and fellow medical team members? Are we really delivering the best care we can deliver? And are we pursuing and living our mission, vision and values?” And I want to go back to that routinely because the board meetings ought to start with that and a question that a board member ought to ask somebody who is being asked to join a board is, “what are your values?”

And it’s amazing to me how often that doesn’t come up in board interviews. Now, a few other thoughts, you know, again, people who are going to sit in on boards that need to ask “am I qualified? Am I qualified really?” I don’t mean in medicine, but I mean to have the right discernment, to understand when there are disturbances in the force and how to in a socially appropriate way, ask the right questions, not to get in the way of the CEO, but to hold them accountable to the mission, vision, and values. What percentage of the board’s time is spent on quality and safety and professionalism issues? Is it something that’s covered at the end of the meeting just sort of, as we’re trying to get out the door? What are the responsibilities of the board’s quality committee? Is there really a quality committee meeting?

And on the board that I currently sit in on a large health system, I’m dying to look at the performance data and not only can I look at the data, I can look at the data today. Because I want access to that performance data to know how we’re doing, and I’m going to look at it. And if there’s a serious safety event, I want it presented to us in this system that I’m a board member. Those serious safety events are presented to the board. We need to know, and there never should be something that’s in the paper that we are not aware of in advance. And so the notion is I need to know that so we are prepared to do the right thing and we’re not going to achieve our quality and safety goals without, and the role of the board is to ask leadership, “what are we doing to make it as easy as possible for our clinical team members to do their work” and consider, especially when we put in a new electronic health record, there are ways to do it and their ways to do it.

And then the second question, what are we doing to ensure that we are supporting the professionals in their full duties and responsibility? Which include, as you alluded to earlier, technical and cognitive competence, but effective communication, respect, respect, respect of others and best practices. And we are supporting them in doing everything they have to do in group and self-regulation, that’s what a board can do. They don’t get in the way, but they ask the questions of leadership, “tell us what you’re doing.”

[01:07:44] Karen Wolk Feinstein: I have to thank both of you. This podcast has given me an invaluable asset. I sat on two quality patient care committees for two systems, and I’m going to send the leadership a link to our podcast because I think this is a topic… do you know what is never been brought up? This is a topic that we need to discuss, critical to patient care, safety, and quality. So this is invaluable. I hope other listeners will also have the opportunity to share this. I think that this is a board conversation. Boards have a committee where this conversation should take place. And as I said, your contribution today has been in measurable. So I thank you both, the Tom and Gerry show was absolutely excellent. I’m much more informed that I was an hour ago. Thank you so much.

To learn more about the effort to establish a National Patient Safety Board, please visit npsb.org. We welcome your comments and suggestions. If you found today’s conversation enlightening or helpful, please share today’s podcast or any of our other podcasts with your friends and colleagues. We can’t improve the effectiveness of our health system without your help. You, our listeners, friends, and supporters are an essential part of the solution.

If you want a transcript or the show notes with references to related articles and resources, that can be found on our website at npsb.org/podcast/. Up Next for Patient Safety is a production of the National Patient Safety Board Advocacy Coalition in partnership with the Pittsburgh Regional Health Initiative and Jewish Healthcare Foundation.

It is executive produced and hosted by me, Karen Wolk Feinstein. Megan Butler and Scotland Huber are my associate producers. This episode was edited and engineered by Jonathan Kersting and the Pittsburgh Technology Council. Thank you, tech council! Our theme music is from shutterstock.com. Social media and design are by Lisa George, and Scotland Huber. Special thanks to Robert Ferguson and Steven Guo. Thank you all for listening.

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