Robert A. Dowling, MDPhysicians in almost all settings are facing extraordinary changes in the way health care is delivered, documented, evaluated, and reimbursed. While the pace of change in medicine is furious, it is not unique to health care and one need not look far for examples of successful and failed management of change in other industries.
A common theme in management books and courses on the subject is that an organization’s culture is a strong determinant of successful adaptation to change (bit.ly/Transformationefforts.) “Culture” was Merriam-Webster’s “word of the year” recently, and can be defined for the purpose of this article as “a way of thinking, behaving, or working that exists in a place or organization (such as a business).”
Physicians may not be accustomed to examining their practice culture generally or specifically as a predictor of successful change management. Moreover, the shift to value-based reimbursement and externally imposed measurement of quality is certain to bring practice culture to the forefront. If culture, then, needs to be addressed in order for a physician practice to transition successfully to fee for value, how does one get started?
Also by Dr. Dowling: How will quality be measured under MIPS?
One simple step is to measure culture with a questionnaire that has been developed by the Agency for Health Care Research and Quality (AHRQ) in the area of patient safety and health care quality. This instrument is currently free, relatively easy to administer, and standardized to permit benchmarking (bit.ly/AHRQsurvey).
The survey instrument is available together with a user guide and technical assistance from the AHRQ website (bit.ly/AHRQsurvey). Designed to be self-administered, the survey should be given to all members of a medical practice for the most accurate results-including physicians and owners of the practice, clinical staff, administrative staff, and anyone else who works in the practice. If a practice has multiple locations, the survey should be “location specific” for best results, as the culture can differ between locations.
The survey is about 50 questions and covers topics including availability of charts and results, status of medical equipment, information exchange with other providers, working environment, communication and follow-up, and questions related to governance and support from leadership. It should take no longer than 10-15 minutes to complete.
How do you interpret the results? The AHRQ has compiled the responses of over 4,000 survey recipients into a database, which includes 219 in the specialty of urology. In addition to benchmarks on each question, the AHRQ has also created composite benchmarks in 10 different domains for a more comprehensive view of the practice culture. The results can be analyzed by group size, specialty, ownership model, geographic region, type of respondent, and years of tenure in the office.
The basis of comparison is an index called “average percent positive score” in each of the domains, and the premise is that a significant variation below that average in a particular domain could serve as a guide for addressing issues in the practice that contribute to the culture of safety and quality.
For example, one of the domains is “Communication about Error.” If a practice had a lower positive response rate (generally five percentage points is recommended as a significant threshold) than peers, it might wish to examine the results of the four contributing survey questions to design an action plan. Benchmarks are included for the entire domain and each contributing question. Those questions include:
How does urology stack up against the other specialties? Urology ranked second highest (average of all composites positive response rate) among nine specialties listed in the database, with general surgery highest and orthopedics lowest. Within the specialty of urology, the highest composite score was “patient care tracking and follow-up” and the lowest score was in the domain of “work pressure and pace” (see figures).
Bottom line: The AHRQ has provided a do-it-yourself tool for assessing the culture of patient safety and quality in your practice. This is a small step practices of any size can take with minimal effort to determine areas of strength and opportunities for improvement. The ability to compare your results to those of other practices may be helpful as you evaluate the culture of your practice and your readiness to navigate change.
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