A Physician Management Infrastructure

THE HEALTH MARKET IS RESPONDING TO THE NEED TO improve the quality of care. Health care leaders are now held accountable for hospital and health system outcomes and this is appropriate. Patient outcomes are determined by the performance of multiple clinicians and the context in which care is delivered. To improve quality of care, physicians, nurses, and managers, each with their distinct knowledge and frames of reference, must collaborate. Despite quality improvement (QI) efforts, empirical evidence that patient outcomes have improved is minimal. One of the reasons for limited progress is insufficient engagement of physicians in QI work, thereby inhibiting successful development and implementation of interventions. Physicians bring unique skills and perspectives to QI, yet their involvement is rare. One barrier to physician involvement is an underdeveloped physician management infrastructure. Hospitals generally have flat physician management structures organized around physicians caring for their individual patients. Physicians are granted privileges to admit patients and oversee their care, and hospitals, in turn, provide nursing care, technology, ancillary staff, and hotel functions. Medical staff are usually organized through a medical executive committee, often including a chief medical officer. Physicians may also serve, most often voluntarily, on hospital committees (eg, quality or pharmacy and therapeutics). Outside this committee structure, however, each physician is generally autonomous, providing and monitoring care for individual patients. A physician management infrastructure is also needed in outpatient settings to establish and manage medical homes and participate in accountable care organizations, and to monitor and improve quality. To improve quality of care, health care organizations need to manage the care of individual patients as well as patient populations. This requires an infrastructure to design interventions, develop performance measures, monitor performance, implement interventions, and monitor their impact. Physicians’ training and their unduplicated perspective on patient care make their contributions essential to assess whether interventions are evidence-based, feasible, and account for patient variation; to ensure evaluation measures are scientifically sound and risks are small; and to develop strong support among the medical staff. In short, physician leadership is needed to practice evidence-based management as well as evidence-based care. The work of improving quality currently rests primarily with hospital administrators and nurses, with physicians assuming a peripheral volunteer role, often questioning the wisdom of these efforts. Physicians need to help lead improvement efforts, yet time physicians spend on QI projects is time lost generating practice revenue. Five changes to the physician infrastructure can meaningfully support quality and the ability to manage patient populations: physician leadership development; greater support for physician quality leaders within care areas and product lines; organized unit-based care teams; continued development of reliable and valid performance measures; and use of these measures to create a chain of accountability from the hospital to physician leaders. The health care industry needs to build physicians’ technical and adaptive skills to lead QI efforts. Physicians can create professional societies to improve the science of health care delivery and participate in formal training. Physician quality leader infrastructure in hospitals could be based on the well-developed nursing management infrastructure in which each patient care area has a nurse manager accountable for staffing and the quality of care in that unit. These unit-level managers report to a departmentlevel manager who reports to a director of nursing. Hospitals can create a similar structure in which a physician is supported for a portion of his/her time to improve quality of care. These physicians can work with nursing and administrative leaders to jointly lead QI efforts as is occurring in some systems. Patient care could be organized into unit-based teams. The patient care area is the microsystem for QI efforts. Many hospital-based QI efforts emerged from the inten-