A Primer on Operating in a More Transparent World
Q&A with Dr. Jeffrey Turnbull, Chief of Staff, The Ottawa Hospital, Ottawa, ON, CAN
As U.S. hospitals come to terms with reporting and publicly sharing quality metrics and patient satisfaction with physicians, hospitals, and emergency departments, it's interesting to note that Canada has been doing it for years. In fact, they operate in an even more transparent environment and feel the same pressures to deliver higher quality at a lower cost. Here, Jeffrey Turnbull, MD, FRCPC, Chief of Staff at The Ottawa Hospital (TOH) and former president of the Canadian Medical Association, shares his thoughts on creating and sustaining a culture of high physician engagement in a transparent world.
HR: Physician alignment can be challenging. U.S. organizations know that signing an employment contract with a physician is just one step in the strategic process. What are your thoughts about that?
JT: Since employing physicians is not common in Canada, they are independent contractors who are credentialed at the hospitals and so must comply with hospital policies. That's really the only hook that I have....and taking that kind of action would entail a substantial legal battle. There are regulatory colleges, but the bar for taking action is too low.
HR: TOH has developed a physician engagement agreement that is signed by each of your 1200 affiliated physicians. How does that work?
JT: Actually, it was originally proposed by our Medical Advisory Committee (MAC). They wanted the hospital to show them more respect and communicate better with them. We used a very iterative process, beginning by asking them what elements they'd like to see in such a compact and then conducting a number of physician focus groups. Imagine our surprise when we recognized that what physicians wanted—quality, compassion, partnership, and respect—matched the hospital's vision and values. And yet, they felt that things were often done "to" them instead of "with" them.
Of course, we had to clarify that "communication and respect" did not always mean physicians would get the outcome they preferred, but they would have substantial input in the decision process and share ownership of the solution. (When you sign off on the budget, you must defend the budget!)
What was interesting though was that when we asked them about the things that irritated them, they were little things—like lack of door hooks in the doctor's lounge—things that cost essentially no time or money to fix—but created much good will from physicians when we addressed them.
HR: And how does accountability for physicians work at TOH?
JT: Administration and physicians are accountable to each other. Evaluations are sequenced to coincide with the credentialing cycle. At that time, they will complete an evaluation on how well they felt the hospital did in upholding its commitment.
Since vice presidents have scorecards that measure their performance, we designed one for the MAC as well that measures baselines and goals with respect to metrics around quality, patient-centeredness, and patient satisfaction...things that physicians can influence. Those targets then cascade down to department heads and then individual physicians.
For example, there is a much higher degree of public accountability and transparency in Canada. And at TOH, we've gone a bit beyond that even. You can find our C. Difficile, MRSA, VRE, and mortality rates right on our website at www.ottawahospital.on.ca, located under "reporting" on the "Quality & Safety" tab on the home page.
So physicians are accountable for things they can impact. With respect to infection rates, physicians are responsible for hand hygiene and appropriate use of antibiotics. We set targets around those and track compliance, including the use of hand hygiene auditors and an antibiotic team. Doctors who don't comply or respond to extra training are quickly escalated to their department head, and after that, directly to me.
In the end, I think the fundamentals remain the same in American and Canadian healthcare. Each of us wants to be treated with respect, be included in processes that are fair and transparent in our workplaces, and be acknowledged for the value we contribute.