Physician Accountability: a Strategy for Leadership and Professionalism

www.gapingvoidart.com

www.gapingvoidart.com

Recently there has been more and more talk at the health system level about the concept of physician accountability.  In Ontario this discussion is part of Patients First LHIN-based initiatives that will have primary care accountable at a local level, possibly with dedicated accountability agreements built into our clinical structures.  The issue became even more prominent at the national level last week after a provocative blog post by former CMA president Dr. Louis Hugo Francescutti, which appeared on the CMA website. He went so far as to suggest that it was time doctors participate in a new social contract; one which had them take a strong leadership position in helping to produce large scale system change, and in doing so become accountable for outcomes. Some doctors were angered by his idea that accountability and professionalism were closely linked.  There were multiple rebuttals by by those troubled by the thought that we should become responsible for enacting what were purely government priorities. They were especially upset by the fact that this was suggested at a time when 40% of the country’s doctors (those working in Ontario) are without a physician services contract and are feeling the brunt of universal clawbacks to their billings. Dr. Francescutti offered a more thorough explanation of his views in an excellent podcast hosted by Dr. Jason Profetto this weekend. It provided tremendous background to his thinking and is a much better context for discussion than an 800 word blog post could possibly provide.

In reading the responses to his post I started to wonder about a few things:

  1. what exactly is physician accountability? Is this our responsibility?
  2. why do doctors feel so threatened by it? And,
  3. if accountable care in family medicine is coming, what will it take to make it effective, achieving wide scale buy-in and promoting positive change?

My previous blog post on Optimism led to conversations with some of my colleagues and friends around a feeling of beleaguerment in physicians. This idea will be explored in another piece of writing, but the beleaguered physician will naturally push back against accountability. He will say that he cannot possibly put another thing on his plate. He cannot be made responsible for fixing a broken system or for dealing with the inefficiencies he sees all around him. Accountability means new work. It means exposing parts of our practises that may not be effective and in fact commits us to improving them.

This seems overwhelming.

But I believe that accountability is unjustly feared. Perhaps this is because many of us associate accountability with blame, finger-pointing, and even shame. When agreements are hoisted upon people from above, in an environment of deepening distrust, then it is easy to see how doctors are worried that in some way such contracts will be used to punish them.

from oikosofy.com

from oikosofy.com

But I don’t think accountability is about blame or fault-finding at all. If implemented correctly it leaves no power imbalance and is bilateral in nature. With active physician participation it does not need to be implemented in a heavy-handed fashion.  It is hinged on measurement,  data, and evidence… something we are all familiar with.

Accountability is simply about matching the desire to to do the right thing, with showing that the right thing is actually happening. It lines up intent with outcomes.

Of course there are many discussions in physician circles trying to address “the what” of accountability (which indicators are meaningful?), “the how” (what are the rules governing measurement and reporting?), “the who” (who has the authority to create and enact these agreements?) and “the when” (how often should we look? When do we have enough data to be accurate?). But these questions cause us to become lost in tactical analysis. The real conversation should be more strategic. It should be addressing the question “why?”.

Why do we need to be accountable?

Many doctors will state that we are already accountable, most importantly to our individual patients. But others argue that in fact we may not be accountable enough to these groups. It is easy to operate as physician islands in a churning sea of care when looking after individuals one by one by one. Our cognitive bias tells us that our patients are incredibly well looked after, and in many cases they probably are . They must be very satisfied, as we are good doctors and they keep coming back! The problem is that we don’t know what we don’t know. We don’t often examine outcomes purposefully and we rarely ask our patients’ about their experience. Accountability involves exposing this information under a critical lens and opening up opportunities for improvement. Not only should we physicians be accountable to our patients as individuals, but we also have a unique responsibility for the health of the larger community that we care for. In population-based care the whole is much greater than the sum of its parts. If we step back and look, we will see many opportunities to improve the health of our practices and patients overall.

Another part of asking “why?” involves the concept of being accountable to our peers. Many of us who work in integrated practises understand this already. Some individual autonomy is given up for the good of the group. We are accountable to our colleagues for our expenses, for our patients’ outside use, and for upholding our own internal codes of professionalism. This allows a reliable and stable practice enviroment to be built. Such a practice has inherent flexibility and can react positively to almost any external pressure. Change initiatives which are supported and adopted by practices such as these are more likely to be permanent and to be effective. Also, once we have looked at our own performance, it is very helpful to compare it to that of our peers. Doing so taps into physicians’ unique personality traits that support accountability: perfectionism, competitiveness, and a keen sense of responsibility.  These can quicken the pace of change.

A third component strategically asking “why?” Involves understanding our accountability to the healthcare system writ-large. In socialized healthcare it is impossible to deny that the behaviour and performance of physicians has a massive system level impact.  Understanding that what we do or don’t do has an effect on system cost and overall sustainability is pivotal here. Measuring and being accountable would show us the effect of our choices and from there we can create programs that garner immediate benefit. Again, to do this well, we must have exposure to reliable data at an enterprise level. Measurement and reporting are key. But a commitment to act on the results of what is being measured is even more important.

Physicians have a huge responsibility for health system improvement. This is not something we can abdicate or delegate, even in the toughest times.

Accountability, in my mind, presents a huge opportunity for our profession. If we have line of sight into our own data first and use it to analyze the quality of our care with the desire for making it the best it can be, then we have taken a very important first step. With that we can begin to compare ourselves to our peers and create meaningful goals and benchmarks to measure against. From there, comparing the same data married to information at the system level provides the ability for physicians to take hold of high-level issues, armed with wisdom and evidence. This will drive meaningful improvement and enhance sustainability.

In showing leadership for accountability we cannot wait to be invited to the table. I certainly hope that we never have to be coerced or forced. Incentives are helpful for starting the process, but they are not all that is required for success.  Measurement and reporting are inherent in the process, and this creates discomfort when it exposes our vulnerabilities. But by starting with intent and matching this to outcomes (both known and unknown), we can lead change. Then we show results that will impress even the most cynical health care planner.

Doctors can set the stage for this new scope of work. We should be involved in the development of meaningful measures. We can embrace reporting to ourselves and our peers but also to the larger health care system. With data and knowledge about where gaps exist we can more purposefully work toward filling them and produce real benefits. In my mind, this is true accountability. Doing this well will show ownership of sustainability issues and great leadership in creating an integrated high-performing healthcare system. This is not about blame or the pointing of fingers.  Is about stepping up and committing to cooperative change. This is the hallmark of professionalism and I believe it is what Dr. Francescutti was trying to convince all of us of when he wrote.

Your thoughts and comments are welcome!

32 Comments

  1. Thank you for your thoughtful and reasoned reflections on the nature of professional accountability rightly understood. I particularly appreciated your definition of accountability as “lining up intent with outcomes”.

    Dr. Francescutti’s proposals were based upon a visit to the Cleveland Clinic during his CMA Presidency. He was part of a larger CMA delegation. The intent of this visit was to gain a better understanding of a very high performing integrated healthcare system and the role that physicians play in achieving that high level of performance,The reality is that physicians individually and collectively make a huge contribution to to the high performance of systems like the Cleveland Clinic, Kaiser Permanente, interMountian , and other comparable integrated systems.

    I believe the goal of the site visit was to consider how these concepts might be adopted and applied in Canada.Given the low ranking of Canada’s healthcare system in comparison to other OECD nations,it is important that we consider roles that our profession could play in enhancing the performance of our system.

    One of the most significant features of high performing healthcare systems is that the physicians providing care are integral to the system rather than being independent contractors. They are selected for their interest and willingness to work as members of a cohesive team. The “peer review” that Dr. Francescutti refers to in these systems invokes real-time performance feedback to physicians with very robust QI support. Physicians who work in such systems welcome this colleagial support. It is not oppressive or “blame-based”.

    It’s unfortunate that Dr. Francescutti’s posting invoked such a virulent initial response.It’s also unfortunate that the CMA elected to take down his posting as that carries a inference of censure.If we censure colleagues who make us think critically about current realities and future possibilities, we close our minds and turn backs to exciting leadership opportunities for our profession. . .

    • Dennis,
      Thanks so much for the backgrounder… he made that very clear in the podcast. And the evidence about high performing health systems, accountability and physician compensation models are hard to counter! There are examples all over the world: some you have listed, and some in Europe as well, such as Jønkøping in Sweden. Each of these systems has physicians that have deeply embedded themselves in a culture of Quality Improvement and the accountability/measurement that goes with it. Bit with you, I am preaching to the choir!
      I do appreciate you taking the time to write such a long thoughtful response!
      Darren

  2. Louis Hugo Francescutti

    March 20, 2016 at 11:40 pm

    Dr Larsen

    I really like it and appreciate your soothing thoughtful response. Last 800 word blog I will ever do for a long time!

  3. Fantastic Post Dr. Larsen!

    I feel pretty strongly that the system would have to change drastically to allow for the data to be collected. This change would be wonderful, but it definitely would be a huge change!

    We need a National EMR/EHR to collect data and analyze it.

    We need a feedback system that would allow patients, nurses, physicians and other allied health to provide feedback associated with encounters and the data attached to those encounters. Simple online forms would suffice.

    We need audits to be set up at set points in a physician’s career to asses their quality of care provided, and to provide supportive and educational feedback to promote improvement, and not consequences. To truly provide engaging feedback, an assessment/grade/punishment should not be included.

    And, we need to be more engaged with communicating feedback to our colleagues without being scrutinized or challenged. I feel like the large egos in medicine prevent productive improvement processes.

    These are just a few of my thoughts and opinions, and thank you and Dr. Francescutti for speaking loud and clear!

    Leaders do what you both are doing.

    • Great ideas for what is needed in implementation Will. Even only one would be a good start! Thanks for leaving these …. I know you are a system leader in the making !!

  4. Darren Larsen,
    You have unfortunately set up an irrelevant strawman argument. The physician community’s response to Dr. Francescutti’s article did not indicate an opposition to accountability. Rather, responders bristled at Dr. Francescutti’s unfounded suggestion that doctors are lazy, unethical, incompetent, lacking in compassion, and greedy. Dr. Francescutti’s proposal to ensure physician accountability was seriously flawed and Canadian doctors were not shy to point its many shortcomings.
    – Maggie Gordon

    • Thanks Maggie! To be sure there were a broad range of responses to his post. Each has focused on an area that is meaningful to the individual doc. I am hoping to take the conversation to the next level, and as such feel okay about the straw dog and would argue that it is quite relevant. We need to think broadly about accountability and find creative ways to answer the questions about why we should do it. Louis just gave a few of us great incentive to carry it on!
      Thanks again.
      Darren

  5. Louis Hugo Francescutti

    March 21, 2016 at 11:16 am

    Maggie,

    Thanks for your comments, let me try to clarify.

    Here is the data that my unfounded suggestion comes from an Ipsos Reid poll done in 2013 that measured what Canadians think of doctors.

    Public Perception of Canadian Physicians

    2003 2013
    Hard working 74% 63%
    Well-educated 75% 62%
    Dedicated 71% 51%
    Trustworthy 70% 46%
    Up to date 60% 36%
    Compassionate 61% 35%

    Not sure where you got the greedy, lazy and unethical from that you mentioned?

    I am concerned, as all Canadian physicians should be, that if this poll is correct we have a very different opinion of ourselves than the public does.

    If you want to chat about it let me know.

    Never has there been a greater opportunity for our profession to shine than right now.

    Louis Hugo Francescutti

  6. Candace Bradshaw

    March 21, 2016 at 11:59 am

    Hi Dr Larson,

    I am a hard working Family Physician in Manitoba who co – owns and operates a busy Fee For Service Clinic with my clinic partners. I am currently ending my first year of a multi year year lease.

    I fulfill more than my share of required CME credits every year for the CCFP as well as our Provincial Regulatory College. I earned and maintain my FCFP. I participate in random MPAR peer audits through our Regulatory College. I participate in large scale research put on by Manitoba Health which follows my stats , as well as my colleagues’, on our quality of care provided for various chronic disease and preventative medicine indicators. I am notified of my results regularly every 3months and our results are shared with all clinics participating.

    I will continue to dedicate myself to providing excellent care. I am not afraid of being measured or being “accountable”.

    I am doing my part to provide responsible evidence based medical care. I turn down requests for unnecessary testing regularly, and decline antibiotics for viral infections regularly. Patients are not always happy with that . In turn I may be at risk of not measuring up at my annual review . I would then be in breech of my lease . Out of business.

    This is an efficient clinic. We are very responsible with taxpayer dollars . Have you seen the numbers for Government operated clinics ? The cost to taxpayers for layers of administration is shocking. Where is their accountability ? If we ran our clinic the way Government does we would be bankrupt in 1-2 months.

    Candace Bradshaw

    • Thanks Candace. Glad to here that you are doing so much that is good for your patients, and considering accountability as part of that process. I think you have it spot on. Accountability is a two way street (and three way if you throw patients into the mix!) which is part of what I was trying to capture. Glad you reached out from MB and commented… Things are very similar all across this huge country! Appreciate your insight to no end.
      Darren

  7. Thank god. Physicians with contract renewal yearly? Very poorly thought out.

  8. A wonderful contribution. Thank you for this very thoughtful piece Dr Larsen!

  9. Thanks for this Darren…I think that having a conversation about accountability is really important and I appreciate your blog post. The three layers that you have noted line up in many ways with the “social accountability” layers that we hold implicitly as family physicians (micro – patient, meso – practice/community, macro – policies/public health).

    One of the challenges that I see is that physicians have need of support in order to be able to embrace the notion of accountability. In order to move to the “meso” level, there is a need for education, practice coaching to simplify the process, and supportive clinic structures. There is a need for logistical support – perhaps staff support, robust interconnected EMR’s, etc. And there is a need for adequate HHR. When I think of the region in which I work – NW LHIN – which has 5 years LESS life expectancy than the best LHIN, higher rates of most of the health challenging metrics (obesity, smoking, inactivity) etc., – I am aware that one of our great challenges is the inadequacy of physician human resource in the system. With communities that should have 7 docs, having only 2 or 3 to provide all of the services (primary care, 24/7 ER, inpatient, palliation, etc) AND do the system work, I am aware that holding those docs accountable for outcomes risks making the invitation to work there even less appealling. The accountability conversation needs to be a collaborative conversation with the MOH and LHIN’s committing to adequate resources (HHR, EMR, etc) in order for docs to do the work that they do best.

    I think that we need to be the change that we want to see. On many days, I am quick to wish for better accountability in the services that I want to have support my patients ie. “Why is the wait list for “x” so long? Why is the transcription so delayed? Why is the gap with X service provider so wide that my patients are falling through it?” When I find myself thinking those kinds of questions, I recognize that what I am asking is not just the “why” but implicit in that, the “who is responsible? why can’t they fix that (because clearly they too know that this is a problem)?”. I am quick to want other agencies and administrators and physicians to be accountable for the things that make my work life feel hard and my patients’ lives harder. I am slower to turn that lens on my own work, and yet I know that there is real value in doing so and every time I have, I have discovered things that I can do better… although it is not always easy and I am not always successful.

    This is an important conversation and I am grateful for your blog.

    • Sarah …. Thank you so much for an incredible, detailed and well thought out response . I agree with all that you say . Accountability is not necessarily just for outcomes, it may also be for process even if outcomes are beyond our full control. You are right about sometimes “just wanting someone else to fix things” and then realizing that in many cases we are that someone! I think that collectively we can do much to make things better!
      Can’t wait to discuss more with you !
      Darren

  10. Thanks for this well written article – it is comforting to know there are people like yourself providing leadership in this arena. After 16 years working in primary care IT, I can honestly say this is a critical discussion that I sadly see little appetite to discuss.

    I am curious as to your perspective on the consumer/patient. From my experience there is a disconnect in terms of the average persons understanding as to current gaps and opportunities (and perhaps a lack of caring) and with it a lack of social pressure for change. Isn’t it ultimately the consumer that should expect a different type of service and level of accountability? And if so, what needs to change for that to happen? Not all physicians practice like Candace yet many patients are unaware of the difference.

    Nick

    • Nick, thanks so much for the feedback and for saying that this post spoke to you in a positive way. My ultimate goal is to make people think… They don’t have to agree with me, but if they have considered the topic at all then this is success in my eyes. I think there is a strong role for a triangle in accountability, which I only barely touched on in the blog. The ultimate triangle with trilateral accountability would be clinician – system – patient. Every doctor I know is incredibly hard working and thinks about patient care all this time… And they work tirelessly go provide good service. Yet in many cases experience and satisfaction scores are middle of the road. There may well be a disconnect between what the clinician knows he/she is doing and what the patient senses and sees. We can do a lot to expose the incredible “behind the scenes” effort without necessarily blowing our own horn. I know that many of us physicians haven’t been well trained in this and are more comfortable working away in the background, seldom seeking credit. This speaks to the way we were trained and our identity. But there is something to be gained in transparency and bringing patients into the accountability loop. Would love to hear your ideas! Perhaps a topic for a whole other piece of writing! Thanks again for taking the time to write.

      Darren

  11. I love the idea of “pod accountability” where a small group of physicians meet to assist each other achieve acceptable outcomes and to support each other in actual practice. Somehow patients and the larger social community would have to be involved.
    Let’s face it, self regulation as practiced by the CPSO doesn’t work for physicians or patients and it certainly misses the mark to provide meaningful accountability.

    • Anne… That is an excellent idea! We learn best from each other in a peer to peer capacity. If we are going to educate about the why and how of accountability I think this is a perfect way to do so. Thanks so much for your comment !!
      Darren

  12. I am trying to find the Ipsos Reid poll done in 2013, referred to by Dr. Francescutti:

    Public Perception of Canadian Physicians

    2003 2013
    Hard working 74% 63%
    Well-educated 75% 62%
    Dedicated 71% 51%
    Trustworthy 70% 46%
    Up to date 60% 36%
    Compassionate 61% 35%

  13. Louis Hugo Francescutti

    March 22, 2016 at 10:09 pm

    Peter,

    It was commissioned for the CMA and presented at General Council by them in 2013 I believe.

    You can contact the CMA and they should able to find it for you. Dr Owen Adams would be your contact.

    Louis Hugo Francescutti

  14. Thank you for your thoughtful blog and for Louis triggering it. My first reflection deals the fact that accountability cannot be defined, let alone be asked from us, without knowing what our responsibility is. Since the late 80’s, our responsibility as physicians has changed considerably, mainly by expanding. As Silversin wrote, “The deal has changed.” Do we really know what the new unwritten deal is? Once that is clarified, the responsibilities, and the accountability will become clear. Every deal has a ‘give” and a ‘get’. In the old deal, our ‘give’ was to see patients and deliver care as we, the physicians, defined it. The ‘get’ in the social contract was autonomy, entitlement and some degree of protection. Nobody told us that the deal has changed. Today the ‘give” is patient-focused, we are expected to collaborate and delegate some authority, and to improve the outcomes of the care we and the system give. Our new ‘get’ should include: physicians can influence the system’s governance, system efficiency and sustainability, and compensation linked outcomes of organizations & individuals. Have we clearly defined these four elements of the new, unwritten social contract: the ‘give’ and the ‘get’ of physicians, and the ‘give’ and the ‘get’ from the system and society? Those four elements define real responsibilities rather than today’s vague expectations. Defining the gap between those responsibilities and the outcomes, defining reasons for the gap, and learning how to close that gap, form the basis of accountability for both physicians and society. My second reflection is around the discomfort some have in closely linking ‘accountability’ and ‘professionalism’. After 30 years, I still cannot define professionalism. One recognizes it when one sees it, yet difficult to define. Some believe that accountability is part of the definition of professionalism, some believe it is not. Only dialogue can bring us closer to answering, what is professionalism?

  15. Signed, John(y) Van Aerde

  16. John (NEON8L) your comments are extremely important and I really wish that we would be able to expand the discussion to include your points. I agree that many physicians have been left behind while the architects of the new relationship between physicians, patients and the government have just assumed that everyone understood what was going on. Our own physician leaders have not been terribly successful in not just communicating the change but presenting compelling arguments in favour of the change. This current interest in measuring and providing surrogate arbitrary benchmarks for whatever it is that really indicates high quality medical care has not led us closer to this goal. It certainly has, however, cost us much more in terms of bureaucracy, creation of managment employment, diversion of physician time and energy and by convincing politicians that they can control the health care system without the genuine input and buy-in by the majority of physicians.

    If it is possible for corrupt, incompetent governments to convince millions of people to re-elect them to majorities in valid democratic election, it should be possible for someone to convince a few thousand doctors to buy in, with eyes wide open, to a “new deal” with the public and the government. And by this, I do not mean using bribery, as may have been tried in the past. I mean using persuasive, cogent, understandable arguments that doctors can understand and reconcile with their own realities.

    At this stage, however, we don’t have such ability. The government is not giving our leaders the ability to lead, since our leaders are not taken seriously as partners. Physicians are treated poorly and are not treated truly as partners. Patients are not being told the truth about the health of the health care system; the public is being blatantly lied to by politicians. There is no trust. There is precious little good will. Sorry to say, but the opinions of the physician leaders chosen by government and government agencies are not really taken too seriously by the rank and file.

    How then, to effect change in such circumstances? Something’s got to give. My opinion is that government needs to own up to the public about the mess things are in. Government needs to honestly commit to working side by side with physicians as partners. In turn, I believe that physicians will welcome working to repair the system. We will all have to be open to things we may not be comfortable with, whether that is higher degree of scrutiny of physicians and their patient’s outcomes, or whether that is the idea of introducing measures to better fund our system through some sort of private measures. The era that allows me to have a personal conversation wtih Darren Larsen at midnight can allow thousands of people in health care to have conversations with each other. Somewhere within these voluntary, engaged discussions are the answers to our problems. This is one of the hidden, untapped resources we need to exploit.

    Paul Hacker
    Ottawa

  17. Era 3 for Medicine and Health Care – Berwick – JAMA online, March 3, 2016.
    dol: 10.1001/jama.2016.1509

    Don Berwick’s two-page reflections link closely with the issue around this blog. Worth reading.

    John Van Aerde

  18. Great blog!

    When I see the term “accountability” I cringe a bit because it is often gerrymandered into the implication that we as physicians are somehow answerable to “health authorities” or other bureaucratic hive-minds. We should consistently be aware that the motivation of the bureaucracy is often incongruent with our motivation as professionals.

    Perhaps we should always, without fail, be specific by following up that our accountability is to our patients. Whenever the word “accountability” is uttered, the words “to our patients” should follow. There cannot be any confusion about this.

    • Thanks Dr. Cooper!
      I think that accountability to our patients is implicit in our contract to care for them. We know this. We sense it and feel it in every interaction. It is part of the unique relationship we have with our patients as we care for them. I am trying to take this same sense and carry it one or two levels higher, as I have described with professional accountability to our peers and others we work with closely, and even to the health care system, to contribute and be the best we can possibly be. For accountability to truly work, though, it has to be bi-directional. It is not enough to just have a one way flow of trust. So this forms an interesting new dynamic in a triangle with patients, peers and the system and accountability flows back and forth in three exchange systems. It is tough to just assume that this trust exists… it has to be built. We do this with our patients and to a degree our professional counterparts, and now it is time for the same to happen at the system level. This is definitely going to be work!!

      Thanks again.
      Darren

  19. Accountability to patients is a great idea but is would have to be meaningful.There would have to be a way to measure not just patient satisfaction but outcomes as well. The outcome may measure quite differently between the patient and the physician . Confidential patient surveys, satisfaction comments will have to be done. Patients could review their own records to ensure that what is written down reflects what they are trying to get across. They should be invited to add to the record.
    There would have to be independent patient coaches who could assist the patient in doing this job. Should they be paid as the members of licensing bodies are paid.

    • Those are excellent ideas Anne! I love your thinking about patients having access to their records and am a huge fan of the open notes concept . Truly integrated accountability with patients and transparency would have to include this.
      Thanks so much for raising this!!
      Darren

  20. we had an awesome debate about this (well, accountability as a whole in health care, not just accountability of the physician) and whether it hinders improvement) at the BC Quality Forum. You may enjoy it: http://qualityforum.ca/does-accountability-hinder-improvement/

    We are all afraid of arbitrary scrutiny or more data collection just for the sake of data collection. Meaningful feedback to drive better care is not scary – it’s long overdue. In the end, I think we can’t help but acknowledge that real accountability is essential for improvement.

    Jessica

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