Patient Experience and Practitioners: Perfect Together?
A great deal of attention has been paid to the patient perception and experience of the health care provided to them. Indeed, patient experience has assumed a prominent position in the determination of the quality and value of health care.
Increasingly, provider compensation is being tied to a series of quality and safety metrics including patient satisfaction/experience ratings. The Value Based Purchasing (VBP) program of the Center for Medicare and Medicaid Services (CMS) assigns 25% of the value based withhold to this metric alone.
Many other insurers have developed separate and similar schema for factoring patient satisfaction into quality based purchasing metrics. Numerous websites are devoted to allowing patients to comment directly and rate providers on a number of indices.
Before your organization can achieve patient, staff, and physician satisfaction through an employment model, leaders first need to identify what they want to accomplish in the community.
All hospitals can agree that they want to:
- Provide great care to the community, which results in high patient satisfaction scores
- Achieve hospital success, as measured by staff satisfaction scores
- Achieve physician success, resulting in high physician satisfaction and loyalty
Your organization’s objective is to balance and accomplish all three goals. When all three goals are met, the result is a true patient-hospital-physician partnership. But how does an organization achieve this?
In the book Good to Great, Jim Collins raises the concept of who’s on the bus and who isn’t. Their research into what characterizes organizations that make the leap from good to great demonstrates that a disciplined approach to determining which individuals fit well into the organization and which do not is a key determinant of success for achieving outstanding organizational performance.
The present question to be addressed is how to identify those practitioners that will benefit your organization and those who won’t. The decision about whether to let someone enter your organization should follow a five step process.
The first step is to recognize a fundamental observation that past behavior is the best predictor of future behavior. The second is to determine in advance the competencies desired in a physician employee. The third is to apply the established best practices of credentialing to the application process. The fourth is use behavioral based interviewing to determine the applicant’s “soft traits” including character, communication skills and ability to collaborate. The fifth best practice is peer references.
Step 1: How to Predict Future Behavior
The first is to acknowledge that the best predictor of future behavior is past behavior. If you credential a practitioner with less than superb technical and cognitive skills, then chances are that very high quality care will not be realized. If you credential a practitioner with a history of unprofessional conduct in previous clinical settings, then you are likely to get unprofessional conduct in your organization.
Hire someone with a history of documentation deficiencies and it is likely your patient record documentation may be found to be lacking. And so on. The questions then become what competencies are you seeking (Step 2) and how do your capture them in an applicant to your organization (Step 3).
Step 2: Identify Desired Competencies
The second step is that practitioner performance is more than just the technical quality of care or the degree of medical knowledge possessed. It is necessary to determine what aspects or dimensions of practitioner performance are important to your organization.
A more comprehensive framework of physician performance competencies may be helpful in developing this list for your organization. A commonly used framework currently is the one developed by the Accreditation Council for Graduate Medical Education (ACGME) and adopted by the American Board of Medical Specialties (ABMS) as well as The Joint Commission (TJC).
This framework includes:
- Patient Care: practitioners are expected to provide care that is compassionate, appropriate and effective for the promotion of health, for the prevention of illness, for the treatment of disease, and at the end of life
- Medical Knowledge: practitioners are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences and the application of their knowledge to patient care and the education of others
- Practice-Based Learning and Improvement: practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate and improve patient care
- Interpersonal and Communication Skills: practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of healthcare teams
- Professionalism: practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, and understanding and sensitivity to diversity, and a responsible attitude toward their patients, their profession and society
- Systems-Based Practice: practitioners are expected to demonstrate both an understanding of the contexts and systems in which healthcare is provided, and the ability to apply this knowledge to improve and optimize healthcare.
Identification in advance of the multiple performance factors sought in a successful hire creates a clear understanding on everyone’s part prior to casting the net for candidates.
Step 3: Develop a Rigorous Credentialing Process
The third observation is that the competition to recruit certain scarce primary care or specialist practitioners may lead to some organizations putting on blinders and overlooking obvious or apparent concerns about a prospective applicant even if they outlined a framework of desired performance as outlined above.
A sound approach is to apply the basic principles of medical staff credentialing and privileging to the employment process when evaluating an applicant. Credentialing is the process of obtaining, verifying and assessing the qualifications of a practitioner to provide patient care services in a healthcare organization. Privileging, on the other hand, is the authority to provide specific patient care services in an organization within well-defined limits based on applicable factors such as license, education, training, competence, health status and judgment.
Although this may strike some as bureaucratic or losing a competitive edge to other hospitals/health systems competing for the same physicians, the wisdom is that a careful vetting process now prevents much anguish and grief later. In fact, a formal process of application for an employed physician is an excellent opportunity to obtain information and vet it before getting too far down the road with someone who clearly will not work out.
The primary question to be answered at this step is does the candidate have the requisite qualifications, training, experience and professional references to meet the job description developed. Items to be considered here include, but are not limited to, medical school, residency, fellowship, work experience, licensure, professional liability history, hospital or payer sanctions, National Practitioner Data Bank (NPDB) report, AMA Physician Masterfile profile, Board Certification status and any other relevant “information” as to qualifications.
Another great source of information is to “google” the candidate’s name. The diligent organization recognizes that multiple sources of information about a potential employed physician need to be pursued simultaneously.
A credentialing best practice is to develop a checklist that can be used to identify potential “red/pink” flags which require resolution before moving forward with an applicant. This checklist might include:
- an adverse NPDB report
- a malpractice history above a proscribed limit, say three (3) cases within the last ten (10) years
- an investigation by a state medical board
- an involuntary termination of employment or medical staff membership
- a limitation, reduction, denial or loss of privileges at another institution
- a questionable professional or personal reference
- time gaps of less than one (1) month since start of medical school chronologically on a CV
- other items deemed material or relevant
Step 4: Utilize Behavioral Based Interviews
Organizations should utilize behavioral based interviews. The rationale here is to discover how a physician applicant would handle actual care scenarios. The logic is that past behavior is an indicator and predictor of future behavior. Behavioral interview questions generally are more pointed and are designed to probe and elicit more specific answers than a traditional interview.
In a behavioral interview, the employer has decided what skills are needed in the physician to be employed and will ask questions to find out if the candidate has those skills. Instead of asking how you would behave, the question will be how did you behave? Specific examples might include:
- How did you handle a difficult and demanding patient?
- How did you handle a schedule interruption?
- Give an example of when you went above and beyond what was required?
- Tell me how you worked effectively under pressure?
- Have you had to convince others to do something they weren’t thrilled about?
- How have you responded when a nurse raises questions about your diagnosis or treatment decisions?
Some organizations use a variation of a 360 evaluation process in that interviewers include who the physician will report to, peer physicians, and staff who will work with the physician. This type of interviewing provides different and legitimate points of view particularly as to the cultural fit of the individual applicant.
Step 5: Establish Best Practice Peer References
Professional peer references are not optional. They are required to insure the current competency of a practitioner to perform privileges requested at your organization. Many hospitals, however, merely list that “X” number of professional peer references are required without ever specifying what constitutes a legitimate professional peer reference.
The Joint Commission in the medical staff privileging standard, MS06.01.05:EP8, clearly states that a professional reference is a peer recommendation that includes written information regarding the practitioner’s current:
- Medical/clinical knowledge
- Technical and clinical skills
- Clinical judgment
- Interpersonal skills
- Communication skills
Additionally, references obtained should be as current as possible and from knowledgeable professionals who actually have an understanding of the candidate performance either by direct observation or from reports. Your obligation is to clearly state what you need and examples of who might be able to provide what you need. You cannot leave it unspecified and think that the candidate knows what you want and need. Chances are they don’t.
After clearly stating what you require, you can provide examples of who might be able to provide that information. If from a training program, it could be the academic department chair or the residency training program director or the faculty member responsible for the resident performance evaluation. In the case of a reference from another hospital, it could be the department chair, the physician service line director, the physician assigned to perform the candidate’s proctored focused professional practice evaluation (FPPE) or the employed physician group medical director.
Some further examples might include the chair of anesthesiology commenting on the performance of a surgeon. It could also be the medical director of critical care commenting on a medical specialist that uses the critical care unit.
The key thing to make explicit is that the professional peer reference must be from someone who is or has been in a position to evaluate the applicant on the six dimensions or performance above and can attest to the current competency for privileges being requested. That leaves out the pastor, the dentist and possibly the best friend from medical school (unless that friend is now his “supervisor” and responsible for evaluating current competence).
It is almost axiomatic that the rate limiting step in getting an applicant credentialed and privileged is waiting for the professional peer references to be returned to the Medical Staff Services Department. Response times are slow, often agonizingly so.
There are two sides to this equation. The first is that the burden is on the applicant to provide you with the best contact information for his or her professional peer references. The other is that you should have a best practice system for obtaining peer references expeditiously that might include web-based technologies including those available from SkillSurvey.
It is hoped that these five steps will help your organization to identify practitioners that not only “know” but also “care” about every patient touched and treated by your organization.