As physicians and hospitals continue to align, whether through employment, co-management or other partnership models, healthcare leaders are realizing the importance of involving physicians in major initiatives, such as those to meet meaningful use, optimize efficiencies and improve quality. In addition, as collaborative care models such as accountable care organizations and patient-centered medical homes grow, physicians will gain a more central role in healthcare delivery. For these reasons and others, Erik Swensson, MD, CMO of Franklin, Tenn.-based Capella Healthcare, believes physicians need to be leaders in patient safety and quality.
Leaders in action, if not in title
All physicians, whether in formal leadership roles or not, are leaders, according to Dr. Swensson. "Although healthcare is a team, there has to be a coach for the team, and the coach is normally the person with the most experience, training and expertise, and that normally is the physician." The amount of training required of physicians makes them leaders almost by default, he says.
However, physicians can be successful leaders only if they build on their clinical training and knowledge by learning how to teach by example and mentor others. "I don't expect every doctor to want to be chief of staff or play on the national scene, but I do expect them to be safety-conscious and educated in what a culture of safety is," Dr. Swensson says. Unfortunately, medical schools traditionally do not train physicians in leadership skills, which means hospitals have to encourage physicians and invest in them as leaders. "As physicians, we're taught to make the correct diagnosis, to implement the correct treatment — whether medical or surgical — to be compassionate and to care about people. But no one really talked about the process of safety or the culture of safety," he says.
Building a culture of safety
While physician education is starting to shift as the healthcare industry focuses more on quality and patient safety, there are already a couple generations of physicians in practice who were trained before a culture of safety was even discussed, according to Dr. Swensson. Building a culture of safety may thus be new and more difficult for some physicians than others.
A culture of safety depends on a belief that everyone has a role in keeping the patient safe, he says. One of the key factors in creating this culture is developing positive, inclusive attitudes toward everyone in the environment, from the custodial staff to the CEO. Just as a hospital CEO's decisions on the organization's policy can affect patient safety, a physician's clinical work and a custodial staff member's cleaning practices can affect infection rates.
While exhibiting this attitude may seem easy for people trained to care for others, it can become a challenge in times of high stress, which hospitals and health systems are no stranger to. The relationship between physicians and nurses can be a particular challenge because they work together so often and tensions may build. Keeping communication lines open for nurses and other staff is critical, especially in a high-stress situation, to ensure safety and quality. Even one instance of failed communication, whether due to misunderstanding, fear or anger, can jeopardize the relationship for all future interactions. If a physician reacts negatively to a nurse's comment or question regarding safety or quality, the nurse may be discouraged from ever speaking up again, which puts patients — and clinicians — in danger. "It the team is afraid to speak up, you can't have a culture of safety," Dr. Swensson says.
As leaders, physicians have a responsibility to respond appropriately to questions concerning safety and quality. "It's a tough business; we're dealing with pain and suffering. If you're going to take that responsibility, you have to be strong enough to say, 'Yeah, I am tired. Yeah, I don't want to hear that I missed something. But I have to look at the big picture, be objective and say to the nurse thank you for reminding me, thank you for stopping me from doing something [incorrectly.]'"
Furthermore, responding to questions on safety and quality should not be one-liners — only a 'thank you' — it should be a discussion. "Physicians should be educators. If you have a student, nurse or physician assistant ask a question, you can't be mad at [him or her]. You have to respond appropriately and answer it," Dr. Swensson says. When he practiced as a surgeon, he says his nurses were not afraid to talk to him or question what he was doing. "And sometimes they would be wrong. And if they were wrong, I would educate them on why I was doing what I was doing."
Solving small problems first to solve bigger ones later
Physicians' relationship with the hospital C-suite is also a critical element of a culture of safety. Physicians and hospital executive leaders can develop a strong relationship by regularly working together in a non-threatening way. "As a corporation, we feel that doctors and the C-suite should have a type of regular interaction that is not crisis-driven," Dr. Swensson says. "If the only time you talk is when you're in crisis, it's a very difficult interaction. But, if you talk about small problems, and what [each other's] philosophy is, then when you hit crisis time, you're much more aligned to take care of the problem."
For example, at each of Capella Healthcare's hospitals, a team of six to 12 physician leaders meet with the CEO quarterly to discuss various issues. Capella encourages the group to meet outside the hospital, such as in a restaurant, to talk about the medical community — what the problems are and how to solve them — in a comfortable environment. In addition, members of the hospital C-suite do rounding with physicians regularly and the CEO has an open-door policy. "When that connection is made, you already know the person and you already have some successes — you know you can solve problems, as opposed to walking in for the first time, both sides feeling like they have to protect their turf," Dr. Swensson says. A positive physician-C-suite relationship can ensure that hospital leadership can confront patient safety and quality issues head-on in a collaborative fashion.
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