Applying Futuristic Technology to the Priorities of the Past

The hot topic in health care executive suites across the nation is outcomes management: measuring the effects of interventions on the quality of life of patients. The halls of our institutions are buzzing about the shifting focus from the board room to the bedside, and from the balance sheet to the patient's chart. Is outcomes management just another fad that will result in an additional layer of space-age overhead with little relevance to our patients' goals? Aren't we already concerned enough about our patients? What happened to the old saw, "If it ain't broke, don't fix it?"

At least one group--consumers--insists that our medical care system is "broke." They're complaining to their neighbors and to politicians. Recently, 89 percent of them told Louis Harris pollsters that our medical care system needs a major overhaul.(1) And their politicians are listening carefully.

Although few consumers consider it wise to confront providers face to face, they routinely roast us in beauty shops and hardware stores. Discussions often swing to medicine and to hospital bills and doctors' incomes. They don't sense physicians' concern for their health outcomes. This group pays our rent and makes our car payments. Professionally, they are the reason we exist. They're our patients, and they're not pleased. What's gone wrong? And what can physician executives do about it?

Our first task may be to convince physicians and others in our organizations that physicians' status with patients is actually as poor as measured in the Harris poll. Those who have been confronted or sued by a disgruntled patient need no reminder. However, there is a residual reservoir of good will toward physicians, and some patients will avoid offending their physicians because of future health needs. They simply swallow hard and absorb what they perceive as inconsiderate or low-quality treatment--until the pollster calls.

We can help the situation through an organization-wide commitment to reestablishing the servanthood of the board room to the bedside. We've become so bogged down by the third-party alphabet soup and by turf battles that much of our energy has been distracted from our patients' illnesses. Our patients need their crowns returned--and to be reseated on the throne of health care delivery.

Next, a parallel commitment of chief executive officers and physician executives to institution-wide quality of care is imperative. This pledge to quality should be so obvious that it permeates every crevice of the institution. Despite the ongoing struggle to neatly define medical quality, we can definitely dedicate ourselves to finding the "Q-word" in every resource management decision.

Paul Ellwood insists that we cannot manage what we cannot measure. He says that most annual reports of health care institutions provide only statistical data such as operative procedures, laboratory tests, inpatient days, and outpatient visits. Usually there is no mention of documented improvement in health. He recommends a national databank of outcomes utilizing quality of life scales to provide feedback on interventions to providers, payers, and patients.(2)

Allocation of some scarce resources may be necessary for patient outcome information systems compatible with a national databank when it becomes a reality. It may fall on the physician executive--the bridge between the cold calculating financial officer and the warmth of the bedside--to be the persuader and catalyst in recommitting the organization to its high calling of not only producing but also measuring health in patients.

Dr. Ellwood also called for physician managers to consider themselves clinicians whose patients are their institutions, probing and evaluating its multifaceted epidemiology of outcomes. A physican executive should be concerned with specific patient outcomes as if it were his or her stethoscope against the patients' chest and signature on the order sheet.

What are some practical implications of clinically evaluating and treating an institution? How do we climb down from our futuristic perch, where we scan the horizon, into the real world of the physician executive?

Ellwood suggests that the American College of Physician Executives is uniquely situated to set industry standards for organizational accountability on interventional outcomes. Physician executives, particuarly members of the College, should encourage the institutional adoption of outcome measurement, utilizing quality of life scales, as a management tool. Physician executives can also promote cost-effective medical treatment research and training in medical school and on residency teaching rounds. Physician executives need to be encouraged to do epidemiological studies of their organizations, looking beneath the philosophic broad strokes of mission and goals. The thousands of pieces of nitty-gritty patient care, like the pieces of a puzzle, when property assembled will reveal the portrait of a well satisfied patient-customer. The study of outcomes should consider ingredients that are almost too obvious to appear in a professional journal but that are nevertheless too often overlooked:

* Rid the organization of rude and inconsiderate providers who make patients feel like nuisances.

* Provide convenient appointments. Should patients need to miss work for routine care? For sudden illness, do they need to choose between a long wait in a noisy, expensive emergency department and a 10-day wait for an office appointment? Could schedulers leave daily gaps for the inevitable overnight illnesses, a daily sick call for those who have toughed it out all night? Patients complain when shifted around like merchandise into gaps in our schedules.

* Require all providers to complete payment request forms for patients. A form that would be simple and routine for experienced billing staff could represent hours of anxiety and frustration for patients. Refusing assistance to patients with these forms is a form of harassment, especially for the elderly.

*Establish performance-based provider reappointment. Patients have traditionally chosen their own physicians and health care organizations after evaluating the "quality" of interventions on themselves and friends. This concept usually singles out physicians. However, all health care workers should be subject to performance evaluations. The public has observed that certain providers earn consistently poor marks, and they wonder why we don't do something about it.

* Avoid bedside nursing shortages contrived for budgetary purposes. That's where the health care "product" is produced and serviced. Only during the last gasps of "institutional air-hunger" should bedside nursing be cut.

* Give priority to actions for patient comfort, such as patient controlled analgesia, that increase hospital costs minimally compared to their positive impact on the patient's experience. Major operation patients who experienced long and painful waits for an overworked nurse to rush breathlessly into the room with a shot will remember. They'll do a bit of negative advertising for the provider--the kind people believe.

* Screen provider practice patterns to monitor resource consumption and provide educational support where indicated. Physician executives uniquely understand both the necessity and the feasibility of cost-effective patient interventions and are, or should be, positioned to have influence on institutional budgetary priorities. The public will soon demand that greater than 56 percent of the CABGs performed are clearly appropriate for both the patient's myocardium and money market fund.(3)

I predict that the future will demand a new species of physician executive, one with special expertise in the pursuit of cost-effective medical care--a quality-resource manager or QRM coordinator. This person will function much as we monitor quality indicators now, but with equal concern for the other half of the quality-cost equation. The QRM coordinator will provide key input on the institution's ethics committee and will testify in defense of staff physicians sued for malpractice when they have acted responsibly. The establishment of documented, efficient care giving not only pumps up the immediate bottom line, but also becomes a keystone in marketing services to payers and consumers.

* Avoid rationing of medical care. Although events in Oregon (eliminated Medicaid coverage of certain high resource consuming interventions to allow funding of basic care for more people) are well intended, does it make sense for our society to withhold needed care? Is there a place for physician executives in the roll of lobbyist for the poor? If physician executives could document for government leaders that we are providing appropriate, cost-effective care, we could compassionately appeal for high-quality care for all citizens.


(1) Blendon, R. "Three Systems: A Comparative Study." Health Management Quarterly 11(1)2-10, First Quarter 1989.

(2) Ellwood, P. Keynote address at National Conference on Health Care Leadership and Management. Washington, D.C., May 1-3, 1989.

(3) Brook, R., and others. "The Appropriateness of Performing Coronary Artery Bypass Surgery." JAMA 260(4):505-9, July 22/29, 1988.

Further Reading

The following additional sources of information on outcomes management were obtained through a computerized search of databases. Copies of the articles cited are available from the College for a nominal charge. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813-287-2000.

What is Outcomes Management? How Does It Work? Hospital Strategy Report 1(5):8, March 1989.

"Outcomes Management: The Next Step Beyond Quality Assurance." Hospital Strategy Report 1(5):1,5-7, March 1989.

Bowen, O., and Burke, T. "New Directions in Effective Quality of Care: Patient Outcome Research." Review of Federation of American Health Systems 21(5):50-3, Sept.-Oct. 1988.

Brook, R., and others. "Assessing the Quality of Medical Care Using Outcome Measures: An Overview of the Method." Medical Care 15(9):Suppl. 1-165, Sept. 1977.

Curry, W. "Outcomes Management: New Name for Old Idea." Physician Executive 15(5):2-6, Sept.-Oct. 1989.

Ellwood, P. "Shattuck Lecture--Outcomes Management: A Technology of Patient Experience." New England Journal of Medicine 318(23):1549-56, June 9, 1988.

Geigle, R., and others. "Outcomes Measurement: A Report from the Front." Inquiry 27(1):7-13, Spring 1990.

Greenfield, S. "The State of Outcome Research: Are We on Target?" New England Journal of Medicine 320(17):1142-3, April 27, 1989.

Lohr, K. "Outcome Measurement: Concepts and Questions." Inquiry 25(1):37-50, Spring 1988.

Ware, J. "Measuring Outcomes: Can It Really Be Done?" Managed Health Care 1(5):14-15,17, Nov. 6, 1989.

Wennberg, J., and others. The Need for Assessing the Outcome of Common Medical Practices." Annual Review of Public Health 1:277-95, 1980.

Williamson, J. "Evaluating Quality of Patient Care. A Strategy Relating Outcome and Process Assessment." JAMA218(4):564-9, Oct. 25, 1971.