I’m a Doctor, Not a Black Belt!

I'm a doctor, not a Black Belt.

I’m a doctor, not a Black Belt.

It’s a cliché, and perhaps because it is a cliché it is too often forgotten, even by experienced process improvement practitioners: you can only improve what you measure. Thus it is inevitable that the effort to improve healthcare encounters the change and cultural issues of getting process stakeholders to support measurement of their performance. Workers in all kinds of jobs are used to having their performance closely measured; athletes are also used to having all manner of stats collected on every facet of their performance. But many other professions are often, for reasons of ego, control, and pride, actively or passively resist the application of metrics to their work. Sometimes, this concern is well-founded — poor metrics can sometimes make things much worse as measures intended to improve things sets off a cycle of unintended and negative consequences. But many times this resistance has nothing to do with the quality of metrics, but the very idea of metrics.

Thus The Wall Street Journal’s recent article on the use of “big data” to track doctors at work resonates with all process improvement professionals. In it Anna Wilde Mathews describes how

Marnie Baker, a pediatrician at California’s MemorialCare Health System {is the} bearer of a serious and, for some of her colleagues, unwelcome message. She’s the voice of a program that digitally tracks their performance, informs them when they don’t measure up — and cajoles them to improve…It isn’t always an easy sell. At one clinic earlier this year, physicians grilled Dr. Baker, who is director of performance improvement at a MemorialCare-affiliated physician group…Cardiologist Venkat Warren said he worried that “some bean-counter will decide what performance is…If is isn’t cost-cutting, what is it?” “It’s providing better value,” Dr. Baker responded.

Encounters like these are one result of the changes sweeping American health care. Technology is making it easier to monitor doctor’s work as patients’ details are compiled electronically instead of on paper charts. Software makers are selling new tools to crunch the data. Software called Crimson offered by the Advisory Board Co. now includes information on more than a half-million doctors, up from fewer than 50,000 in 2009.

To succeed under the new health-care economics, hospital executives say, they must  lean on doctors, who make nearly all the key decisions on what treatment, tests, and drugs patients get. “The last frontier is the physicians,” says Thomas.

, vice-president of clinical effectiveness at Monmouth Medical Center…He ordered up a list of the 20 physicians practicing at Monmouth who were costing the most money and sat down with each to go over their data. Several trimmed services like repeat lab tests and daily x-rays, he says, and those 20 are no longer among the costliest. Their patient-mortality and complication rates also improved, he says.

An interesting change management tactic, and one process improvement professionals in other fields should note, is how

Leery of sparking doctor revolts. hospitals are delivering the feedback in sessions led by fellow physicians like Dr. Baker at MemorialCare, not outsiders. Executives refer to their efforts as “aligning” with physicians, not telling them what to do. MemorialCare, a six-hospital nonprofit based in Fountain Valley California, is keeping detailed data on how the doctors at its affiliated medical group perform on many measures — including adolescent immunization, mammograms and keeping down the blood-sugar levels of diabetes patients. The results are compiled, number-crunched and eventually used to help determine how much money doctors will earn.

Tracking doctors’ performance is “absolutely key” to the future,” says MemorialCare’s CEO, Barry Arbuckle. Wide variation in practices among doctors is “extraordinarily costly,” he says. “Do we control physicians? We don’t try to,” he says. “We just try to use process and information to get them to the same point.”

Some doctors had to go through “stages of acceptance,” he says. “First is anger, ‘Why is someone looking at my data?’ The denial, ‘This s not my data! then acceptance.” MemorialCare says that the doctor-data efforts and other programs have helped reduce the average stay for adult patients to 4.0 days in 2012 from 4.2 days in 2011. It also reduced the average cost per admitted patient and has improved on indicators of quality including patient readmission, mortality, and complications.

Dr. Warren wasn’t persuaded. Regardless of data-tracking and financial incentives,”I give very good care to my patients,” he said. “One-on-one clinical care.” The director of the clinic, David Kim, chimed in. “Well, you’re an outlier,” he said. “Every doctor says they provide good care to their patients,” but nationally, data show that patient outcomes are often bad.