When patients enter a typical hospital, they sense that their needs don’t come first. Nobody seems to listen to them. Nobody seems to care how long they have to wait, or what will happen to them once they are transferred to another service. At times, members of the care team seem to work at cross-purposes.
Rigid hierarchies and competing priorities often stand in the way of patient-centred care. The ability to drive meaningful change remains stymied by an us-versus-them mentality between hospital leaders and the physicians who practise at their facilities. Survey results show that physicians generally distrust hospital management and feel uninvolved in major decisions.
Yet the evidence suggests high-performing hospitals have highly engaged physicians. These organizations tend to have higher physician-satisfaction levels and lower turnover rates. Patient-satisfaction scores are higher and patient outcomes are generally better.
Given the defining role physicians play, their engagement has never been more crucial as funding reforms in Ontario prompt hospitals to find new ways to provide patients with better care at less cost. No meaningful improvements will be achieved without first establishing a partnership of trust.
Seattle’s Virginia Mason Medical Centre has been among the most successful at bridging the gap between physicians and hospital leaders through an engagement agreement that explicitly commits both groups to putting the interests of patients first.
Such agreements are more common in the U.S., where doctors are usually employees and directly accountable to hospitals. These pacts are newer in Canada, where physicians are independent practitioners. They work at a remove from hospital leaders, with incentives that encourage professional autonomy, individual accountability and fierce competition for limited resources.
Five years ago, The Ottawa Hospital became the first in Canada to develop a physician-engagement agreement. The document, created jointly with our medical staff, outlines the values and behaviours that are expected of doctors and the supports they can expect from the hospital to help them provide quality patient care.
As the centrepiece of a broader physician-engagement strategy that includes annual performance feedback, leadership training and a recognition program, the agreement has triggered a culture change. It has put the power and responsibility for quality improvement directly into the hands of frontline doctors. It has also transformed the role of hospital leaders from being top-down administrators to being coaches for those who care for patients.
Since the agreement was introduced, morale among medical staff has improved, rising to the provincial median of 57 per cent in 2012 from 49 per cent in 2009. In addition, more patients have expressed satisfaction with their care and doctors are more involved in improving care delivery.
The agreement set the stage in 2010 for The Ottawa Hospital to become the first in Ontario to participate in the U.S. National Surgical Quality Improvement Program, which aims to measure and improve the quality of surgical care. The program became the first test of how the hospital and its physicians would put into practice a set of commonly agreed-upon values and behaviours. For example, hospital leaders lived up to their commitment to foster an engaged medical staff by offering leadership training programs to enhance and support the skills development of physicians interested in quality improvement. Physicians volunteered their time and expertise to develop assessment and accountability processes to ensure there was organizational support for their quality-improvement efforts.
Today, more than 200 physicians work alongside hospital employees to reduce the rate of complications among surgical patients. Collectively, their work has resulted in lower rates of surgical-site infections, fewer urinary tract infections, shorter lengths of stay and fewer readmissions. Similar partnerships among dyad teams of physician and hospital leaders have resulted in shorter medical and surgical wait times and faster treatment for patients needing urgent surgery.
With a growing number of Canadian hospitals exploring physician-engagement strategies, below are some lessons for organizations contemplating the development of their own agreements.
Honest conversations are essential: Involve physicians in developing the agreement. The idea sounds obvious, but it’s a radical departure for hospital leaders to shift from command and control to listening, asking the right questions and addressing the concerns of the medical staff.
Rally around shared values: Align your organization’s goals, values and objectives with those of the medical staff. Clarify roles, responsibilities and accountabilities.
Enlist the support of high performers when you encounter pushback: “Doctors know there are colleagues who aren’t performing and yet they’re not being held to account, which is bad for morale,” says John Mahoney, a urologist who’s also president of the hospital’s medical staff association. “The people who are performing want to be recognized as high performers. They like having an agreement that spells out clear standards for everybody to live up to.”
The next generation expects to work in a performance-driven culture: “Monitoring quality and quality improvement are ideas permeating through medical schools and residency programs,” says Pierre-Antoine Brown, a 36-year-old nephrologist at the hospital. “These were foreign concepts 20 years ago. Younger physicians are ready to accept these concepts and work as part of a team.”
Accountability is not about blame: True accountability is about meeting expectations and performing jobs in a respectful atmosphere. It’s about providing constructive feedback, learning from mistakes and continuously improving.
Accountability is a two-way street: Hospital leaders, from the CEO on down, need to model collaboration and respectful behaviour if they expect the same of physicians and staff. Performance feedback should be reciprocal, coming from medical staff to hospital leaders as well as the other way around.
Trust doesn’t come from a piece of paper. It requires hospital leaders to decentralize control in favour of open decision-making. And it requires giving more people a say in the workings of the health system. That’s the only way to forge the partnerships needed to provide safe, compassionate, high-quality care for every patient, every time.