The list of healthcare leadership challenges is long, and the pressures for solutions are growing. We are unlikely to find the answers by working longer hours and doing more of what has brought us to where we are. True leadership drives the attitude and behavior changes needed to meet the access, quality, and financial requirements of our patients, communities, and society.
For 20 years, a northern California hospital struggled with physician completion of medical records. The medical staff bylaws required completion within 30 days, but physicians rarely complied. When asked to supply record completion data, the hospital would report a 60 percent noncompliance rate. The Joint Commission would inspect the facility, the hospital would submit a plan of correction, and three months later, the noncompliance rate would be down to 40 percent. Six months later, however, the rate would be back to 60 percent. Despite rewarding physicians for on-time completion, suspending the privileges of physicians with delinquent charts, faxing unsigned orders to physician offices for signatures, and sending medical records department employees to physician offices with charts to complete, the hospital continued to report a high noncompliance rate.
In June 2008,the California Department of Health and Human Services reviewed the hospital’s medical records and found 1,024 deficiencies from 69 physicians. The review concluded that the medical staff had to adopt and enforce bylaws to carry out its responsibilities and complete medical records within 14 days.
The chief of staff called an emergency medical staff meeting. He asked the staff for suggestions on how to comply with the new guideline. This intervention brought about modest improvements in medical staff record completion. To amplify these improvements, he personally contacted providers and encouraged them to complete their charts.
Concurrently, he became aware that, the medical records department was failing to make the charts available to the physicians and provide them with accurate and timely alerts to complete their charts. To address these leadership concerns:
- An outgoing, energetic staff member was hired to communicate directly with medical staff physicians
- Processes were put in place to notify physicians on a timely basis about delinquent charts and to ensure that the charts were available when physicians came to complete them
- The hospital implemented electronic signature software, so that physicians could sign records from their own computers
- Delinquency reports were sent to the CEO and the Chief of Staff, so that they could personally contact noncompliant physicians.
- The CEO and the Chief of Staff informed physicians that they would be suspended from the staff and not allowed to work at the hospital if they did not complete their charts.
- Suspended physicians were required to reapply for staff privileges and pay reapplication fees.
Two years later, the percentage of incomplete charts remains less than 1 percent, a significant drop from the 60 percent rate reported prior to the leadership interventions.
The most significant outcome of timely medical record completion was immediate access to accurate information about recently hospitalized patients. Over this same period, other hospital metrics also improved:
- The number of days the hospital was delayed in sending bills due to lack of complete information dropped by more than 50 percent
- Days in accounts receivable decreased by 15 percent, from 54.9 days to 46.9 days from October 2008 to June 2009
- From 2007 through 2009, the publicly reported core measure composite scores for acute myocardial infarction, heart failure, pneumonia, and surgical care improvement increased by 1 to 15 percent
- The annual satisfaction survey of the hospital’s medical staff also improved. When asked about the quality of care delivered by the hospital in 2008, 17 percent of physicians rated the care as excellent, while in 2010 the percentage increased to more than 42 percent. Asked for their perception of the hospital as a place to practice medicine, 21 percent felt it was excellent in 2008 versus 49 percent in 2010. According to NCR Picker, the organization that conducts the survey, the hospital’s national percentile rankings rose from 25.6 percent in 2008 to 83.4 percent in 2010. A recent Joint Commission reviewer asked whether a new medical staff had been hired, saying that he had never witnessed such a dramatic change.
Leaders are more likely to be successful when they change systems that influence people’s behavior rather than demanding people to change. By changing communication, medical record, and reward/consequence systems, leadership was not targeting/blaming physicians as the cause of the problem but targeting the structure in which physicians work. People’s resistance to change decreases when the affront is not personal but generalized to the system.
Physician and hospital leadership tried one step after another, always keeping their ultimate objective in mind. Each step increased the momentum of the change effort. As visible results accumulated, more people became encouraged to support and expand on those results.
Three steps that may be helpful to other organizations facing similar leadership challenges include:
- Constantly reevaluate and upgrade systems and processes to sustain success
- Celebrate progress publicly. Communicate achievements via your hospital’s intranet and at medical staff meetings, and note any economic gains realized from the improvement.
- Reinvest a portion of revenue gains in amenities that improve the practice environment, such as the medical staff lounge and areas where physicians complete their charts
As always, I welcome your input to improve healthcare collaboration and get it done.
Kenneth H. Cohn
© 2011, all rights reserved
Disclosure: I have not received any compensation for writing this content.