Chapter 29

Improving Physician Decisions

Supplement 15

Improving Physician Decisions

Accountants are increasingly becoming concerned with issues of quality• In manufacturing• And in service industries such as

healthcare

In healthcare, as in manufacturing, it was traditionally believed that quality increases costs.

Japanese manufacturing techniques involving such things as total quality management (TQM) and continuous quality improvement (CQI) are demonstrating that this is not so.

Quality can cost less

• Costs of– Rework– Scrap– Unhappy or lost customers– Product liability

• Often exceed the cost of doing something right the first time!

Studies in places like Pennsylvania have indicated that the highest cost hospitals are not always those with the best outcomes in terms of morbidity and mortality.

Four stages of competitive development of markets• First stage--If you build it they will come

• Second stage—supply catches, then exceeds demand

• Third stage--industry restructuring to reduce capacity

• Forth stage--providers focus on quality and customer value

Studies on improving physician decisions• Physician memory• Cue weighting• Problem definition• Hypothesis formulation• Information search

We will look at three that relate to the new information system installed at Peter Brannan Community Hospital.

Cue• A cue is a piece of information that

assists the physician in determining the patient’s true diagnosis

• A cue can be– A symptom– A vital sign– The result of a diagnostic test

A cue weighting is the importance the physician attaches to each individual cue.

One can actually demonstrate the physician’s decision model through the equation:

Y = a + b1X1 + b2X2 + . . . bnXn

Where Xn are the cues, bn are the weights the physicians attach to these cues, Y is the outcome in terms of morbidity and mortality, and a is a constant,

Brunswick Lens Model

Physician

The Patient’sTrue Stateof Health

Lensof

Cues

Lab test 1

Lab test 2

Xray test 1

Blood Pressure

Pulse

Expanded Brunswick Model

Regression Formulation of the Lens Model

Cues

X1

X2

X3

X4

Xn

Predictability ofthe MD

Rm = rymy’m

Predictability ofthe diagnosis

Ra = ryay’a

Achievement Index

r = ryArym

Matching Index

r = ry’Ary’m

ActualDiagnosis

Ya

PredictedDiagnosis

Optimum Model

Y’a

MD’s SelectedDiagnosis

Ym

PredictedDiagnosis MD’s

Model

Y’m

Y’m = am + b1mX1 + b2mX2 + . . . bnmXnY’a = aa + b1aX1 + b2aX2 + . . . bnaXn

Original list of factors studies in improving physician decisions• Physician memory• Cue weightings • Problem definition• Hypothesis formulation• Information search

Hypothesis Formulation . . .• Takes place when the physician

identifies possible causes of the patient’s problem, (the list of possible diagnoses).

A study in the Journal of the American Medical Association reported that physicians who identify the right diagnosis in their list of possible diagnoses almost always select the correct final diagnosis.

Physicians who select the wrong diagnosis do so because they don’t initially generate and adequate number of hypotheses.

That is not the end of the process, however. Having identified the correct diagnosis, a physician must then select the optimum treatment.

One can also use a regression model to signify the proper combinations of medical inputs.

Regression Model

Yo = ao + b1oX1 + b2oX2 + . . . bnoXn

Where Yo is the optimal outcome given the current state of medical knowledge,

Xn are the medical inputs (prescriptions, treatments, etc.) and

bn are the amount of each Xn

Outcomes Management

• Proposed in 1913 by Harvard Surgeon named Emery Codman– Consisted of tracking surgical patients

to see how their treatment turned out– Objective: Determine the most likely

cause of success or failure

• The AMA essentially ignored the study

Outcomes Management

• In 1919 the American College of Surgeons performed a study of 692 hospitals– 89 met minimum standards– The report was carried to the

basement of the hotel where the presentation was made and burned

Outcomes Management

• Despite its rocky beginnings the concept is receiving renewed attention

• One approach is to build– Clinical pathways– Physician guidelines– Treatment protocols

There are large variations in physician practice patterns• Patients like to think their

physician’s approach is based upon what the research has shown works best, but unfortunately this isn’t true

Why don’t MDs follow the best practices?• They don’t know what the best

practices are• They bog down in the tremendous

amount of information needed to make decisions

They don’t know what the best practices are• Most practices in clinical medicine

have never been tested in double-blind peer-reviewed scientific studies, or even through retrospective statistical analysis.

• Even when they are, many physicians fail to hear the results

• Education is a key

Physicians bog down in the amount of information• The problem is limitations in

human memory

Given this theory, what can medical staffs in small hospitals do to improve physician decisions?• Outcome audits• Encourage physicians to use

existing computer technology to store, organize and retrieve these protocols

What can administrators do?• Install information systems to track

resource consumption profiles by physicians– Link these to outcomes

What can administrators do?• Adopt many of the recent innovations

of manufacturers in the areas of continuous quality improvement (CQI) and total quality management (TQM)– The initial focus should be on eliminating

waste and rework and on improving productivity, customer satisfaction, market share, and profitability

To really work, the system must be clinically meaningful. The system must gather and report clinical data.

The End!