When I got started in medicine, I felt that quality of care meant getting good outcomes. Then someone pointed out to me that most patients get better despite our efforts and that we are often wasteful in our pursuit of good outcomes. Process seemed important at that point, leading me to work on paediatric care pathways. But neither good process associated with poor outcomes nor poor process associated with good outcomes is ideal. One harms patients while the other harms both the people caring for patients and the people paying for the care.
Obviously what we need is both good process and good outcomes. But how do we achieve that in a system that pays physicians fee for service and pays health authorities a fixed amount to meet the expectations set by government?
It won't be a quick process, but there are things that can be done to move it along. We need to encourage physicians to learn about quality. We need to pay them for improving quality. Eventually we need to pay physicians a bonus based on outcomes. Nothing I've suggested here is new.
I have suggested to my professional association, the BCMA, that we work to make these things happen. One good start would be to pay physicians to be quality champions within their health authorities. Based on one champion per 25 hospital beds, with a budget of $70,000 per project, the cost for the Province of British Columbia would be $21 million.
That sounds like a lot of money, but if the quality literature is to be believed, quality efforts actually save money. If we take the time to train physicians about quality, we should see both better outcomes and lower costs. The Pittsburgh Regional Health Initiative has demonstrated this using Toyota Production System based methods.
Pittsburgh has developed Perfecting Patient Care University, a four day program that teaches participants how to use Toyota based methods. All champions would be required to attend along with a non physician clinician with influence in the area the project is intended to address.
We wouldn't expect every champion to succeed but we would expect to see a fair number of physicians to develop an excellent track record of improving results. There would be obvious benefits to the health authorities and to patients, but perhaps more importantly, it would give physicians the tools needed to improve their own private fee for service practices.
Using the metric of one champion per 25 beds, we could expect to educate 300 physicians in these methods. That would amount to approximately three percent of the doctors in the province. We would expect to see some knowledge transfer however, since no one works in a vacuum. We would also expect that some physicians would drop out after one project, making room for others to learn.
The quality champion idea is outlined well in a book by Naida Grunden called The Pittsburgh Way. It's excellent reading.
Once we have physician champions trained, we will be on our way to equipping physicians to enter a payment for outcomes process. This is something quite different from traditional pay for performance, and will be the topic of my next post.
What do you think? I'm interested in your ideas.
