To Gain Physician Support for Quality Management, Hospital Administrators Must Treat Physicians as Customers
Dr. McCarthy is vice president of medical affairs, Columbia Hospital, Milwaukee.
Summary
The process of integrating physicians into a hospital's total quality management (TQM) program is not simple. Physicians will not view TQM as an acceptable strategy in the absence of a positive working relationship with hospital managers. Physicians must see hospital managers as colleagues who can help improve their medical practices both in efficiency and patient care.
The first step in involving physicians in TQM is creating an environment that enhances physician relationships. The CEO should be actively involved with the medical staff, and senior hospital managers should work at cultivating physician relationships. Physician needs and the centrality of the physician-management relationship should enter into every management discussion. Also, managers must solicit physician feedback regularly.
Managers can introduce physicians to TQM by accompanying them to off-site TQM programs for a few days. Managers should also coordinate a continuing education program at the hospital, inviting a physician to address medical staff about TQM. Physicians are more likely to respond positively to one of their peers than they would to a consultant or business manager.
Managers should then invite hospital-based physicians to participate on TQM interdisciplinary teams to resolve a problem chosen by the senior medical staff. The problem should be one that promises to be a quick fix, thereby ensuring demonstrable success of TQM and allaying any doubts. After an initial demonstration of TQM's success, the cycle is repeated. A year or two later, managers should invite off-site clinicians to join interdisciplinary teams on issues important to them.
More than a third of U.S. hospitals have active total quality management (TQM) programs in place. Another third are considering launching such programs in the next two years. How will physicians integral to the hospital's future react to a new TQM program? Will they view it as another management strategy pushed by consultants and destined for failure? Or will they accept it as a meaningful strategy to improve their efficiency within the hospital and even, perhaps, the quality of their patients' care?
The process of integrating physicians into TQM is not in a cookbook. There are no simple steps to success, no Moses to pave the way by separating the waters of cultural discontent. Instead, the process is laborious and time-consuming—taking two to four years.
A successful TQM program must be built on a foundation of a physician-hospital partnership. Physicians as individuals, leaders, and combined medical staff will not view TQM as an acceptable strategy in the absence of a positive working relationship with hospital managers. Physicians first must look on hospital managers as colleagues who can help improve their medical practices both in efficiency and patient care.
Setting the Stage
Senior Management Commitment
The first step in involving physicians in TQM is creating an environment that enhances physician-hospital relationships. This can be most effectively accomplished by a chief executive officer (CEO) being actively involved with the medical staff both personally and culturally.
Personal involvement means the CEO respects physicians, feels comfortable working with them, eats lunch with them in the cafeteria, and becomes involved directly in projects with physicians. The CEO should not delegate this responsibility but should be a visible partner with physicians throughout the organization.
Cultural involvement is much more. It means the CEO genuinely likes physicians, tries to think like physicians, everyday strives to understand the physician perspective, and tries to see the hospital as a physician does in daily practice. The CEO visibly carries the physician perspective into nonphysician circles in the hospital, attempting to imbue the organization with a culture that is responsive to physicians.
Senior hospital managers should also have a primary objective of cultivating physician relationships, and the quality of these relationships should be foremost on the agenda of management sessions. This is not to imply that physician needs have priority over other major concerns of the organization; rather, that physician needs and the centrality of the physician-management relationship should enter into every management discussion.
Customer Research
Central to the physician-hospital partnership is not only senior management commitment but also the TQM principle of customer research. Managers must regularly survey physicians and their staffs to identify and address their needs, then follow up with the physicians individually and as a group. Managers must make a visible commitment to invite them into a partnership and solicit their feedback regularly.
Involving Physicians in TQM
Retreats
To get physicians involved in TQM, the best first step is for senior managers, including the CEO, to get away from the hospital for two to five days to attend TQM programs as a group. Ideally, groups of three or four medical staff leaders and senior managers can listen to speakers—physicians included—address TQM's benefits to physicians and hospitals. The bonding that occurs when these individuals attend an off-site program together is a dramatic step toward understanding TQM and its value for the organization.
Also, senior managers should identify active staff physicians (often primary care and younger physicians) to send to off-site TQM programs. Sending two physicians every two months with a senior manager can create an atmosphere of cooperation conducive to TQM. The hospital managers and staff must achieve a TQM cultural introduction that increases familiarity with TQM jargon and concepts. Slowly this middle management endorsement of TQM will subtly affect physicians' views.
Continuing Education
Next, hospital managers should coordinate a continuing education program at the hospital, inviting a physician to address the medical staff about TQM. Physicians negatively inclined toward consultants and business managers will relate better to a speaker who is a physician. The physician consultant or spokesperson for TQM can elicit the most objective reaction from a physician audience. If this session is reasonable, data driven, and well presented, the physicians may be more curious about and open to TQM, even if they do not accept it immediately.
Teaming Up
Hospital-based physicians should be invited to participate on TQM interdisciplinary teams. After senior medical staff leaders identify obstacles that negatively affect physicians' comfort or efficiency at the hospital, hospital managers should choose an interdisciplinary project that can be successfully resolved, given its complexity and need for capital resources, within six months. Key individuals—bright and able managers and staff dedicated to the hospital as well as to TQM—matched with a hospital-based physician then constitute a team.
The team's mission is addressing a physician need very visible to the medical staff. These issues could include:
- Laboratory data turnaround time
- Surgical infection rates
- Time delay in antibiotic administration
- Waiting time for scheduling procedures
The team should include one or two hospital-based physicians who, by their full-time activity at the hospital, have a vested interest in the hospital's well-being and are available for team meetings. Selection of the hospital-based physician for this team is a crucial step. This physician should be one who responded positively when visiting an off-site TQM program and is willing to commit without bias to the team project.
After reviewing the team's successful results, senior hospital managers can share this information with senior medical staff leaders and then the medical staff at large. The team's project should demonstrate the process of TQM, resulting in an improvement in a system or problem.
Keeping It Going
After an initial demonstration of TQM's benefits, the cycle is repeated. Senior managers should recommit to the process. A physician speaker should address the medical staff, using local success stories as examples. Middle managers should continue an in-depth approach to TQM. Furthermore, managers should invite physicians to participate as team members or consultants to teams for easy successes in the first one or two years.
After two years the system is running—not perfectly, but running. At this point, managers should invite clinicians who are active in practice away from the hospital to join interdisciplinary teams on issues important to off-site physicians. Examples include:
- Quickly locating reports on charts to shorten work time in the hospital
- Locating their patients to reduce travel time within the hospital
- Reducing the number of phone calls physicians receive after completing rounds
- Coordinating rounding times to shorten them and limit follow-up phone calls
Overall, physicians will endorse TQM as a research-based tool and adopt the principles quickly. They will frequently respond that the principles are little different from those they practice in their offices anyway and have a scientific basis similar to what they learned in medical school.
When Columbia Hospital, Milwaukee, opened a new primary care clinic five miles from the hospital, hospital managers endorsed team direction of the clinic. This team consists of a hospital representative, the physician medical director of the clinic, a receptionist, a nurse, and the office manager. The team itself sets the agenda of the meetings; discusses marketing issues; helps decide office hours, charges, and diagnostic codes; reviews charts for information sharing; and addresses process improvement such as waiting time and patient satisfaction.
The enthusiasm, low at first, after nine months is palpable. At one recent meeting, the clinic physician described the process as much like evaluating a complex patient using a number of consultants and seeking the optimal outcome. Here TQM teamwork closed the loop from clinical education to office practice.
The cultural gap is not one between physicians and TQM; rather, it is between the physicians and hospital administrators or the consultants hired by the administrators. Truly looking at physicians as customers can overcome this barrier and provide for a mutually beneficial partnership in TQM.
Steps for Involving Physicians in TQM
- Develop strong CEO-medical staff relationship.
- Cultivate positive manager-medical staff relationship.
- Encourage hospital managers and physicians to attend TQM programs together.
- Identify physician areas of interest for TQM teams.
- Involve physicians on teams that deal with their issues, and make results visible.
One Hospital's TQM Program
Three years ago, managers at Columbia Hospital, Milwaukee, made a commitment to total quality management (TQM). After holding a series of meetings with medical staff leaders, managers made a formal presentation to the entire medical staff. Soon thereafter, the physician directors from the departments of laboratory medicine and radiology attended a national program in continuous quality improvement with the administrator responsible for their areas. Returning home four days later, these three individuals exhibited not only a strong awareness of healthcare quality efforts around the United States, but also a stronger bond of mutual trust.
These three persons gained more by listening to healthcare leaders talk about TQM and share experiences related to their hospital departments than they could have gained in any other manner.
Within 12 months, each of the physician directors actively led his physician colleagues and senior department managers through a TQM strategic planning process using a host of continuous improvement tools. Terms such as "vision," "affinity process," "nominal voting techniques," and "interrelationship diagrams" became the jargon of strategic planning teams that historically had presided over capital request sessions.
Within nine months, each physician director had empowered his management team to establish process improvements for cost reduction and customer satisfaction. Also, each physician director has become an active member of a TQM team looking at issues in other sections of the hospital.
Copyright © 1993 by the Catholic Health Association of the United States.
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