Shifting Mindsets: Impacting Physician Views on Quality and Efficiency Metrics

As the financial viability of hospitals and health systems increasingly depends on metrics tracked by programs like the Centers for Medicare and Medicaid Services (CMS)’s quality program, it is more and more important to engage provider teams in the improvement of these metrics. Since many performance tracking programs are relatively new, it can be challenging to engage established providers who feel that they should be focusing on patient care and patient care only. This is especially true for physicians who have been out of medical school for more than 5-8 years. When these providers started their practice, most CMS measures were either not around or were still being developed.

I find that the key to shifting mindsets around quality and efficiency metrics is as simple as engaging the physician team, aligning the team around a united practice culture and mission, and developing a thoughtful incentive plan. In this post, I outline key ways our team shifts mindsets on quality and efficiency metrics to create a high-functioning emergency department team working toward shared goals.

Lay a Groundwork of Trust and Transparency

Dictating metric goals without building a relationship with the team you are relying on to achieve metric improvements is a futile effort. The best way to shift mindsets is to take the time to fully understand the team’s current mindset. In other words, LISTEN. We find it usually takes two to three months to build a relationship with a team. During this time, it is important not to make any major changes. Forget strategy and focus on listening and understanding the unique challenges the practice faces. It is also important to not only focus on working with the physicians and APPs, but also the nurses, techs, and administrative employees. Everyone plays a critical role in the culture and efficiency of the department. 

The best way to do this is to work with the team in the trenches. Being a practicing physician makes me a much more effective clinical leader and emergency department consultant because I understand the pressures and realities working providers face. Team members respect leaders who do what they say they are going to do, even when challenged by the realities of working clinically.

Align your Team Around Culture First, Not Metrics

It can be tempting to dive immediately into hard-hitting strategies to improve quality and efficiency. However, these strategies will fall flat if your team does not trust you and feel connected to the mission, vision, and values you set forth for the department. Before you set goals, define your overall expectations for the culture of the team. Talk with each member of the team and ensure they believe in your mission and vision. If you need inspiration for your team’s core values, consider these six philosophies forward-thinking emergency departments share. These philosophies are the cornerstone of every high-functioning ED team we have encountered.   

Communicate the Necessity and the Urgency

Once you build trust with your team and are aligned on your vision, mission, and values, you are in a position to communicate the necessity and urgency of improving performance metrics at your hospital. When the team knows that what you are communicating benefits them as much as it benefits the hospital or health system, the conversation feels less like orders or criticism and more like what it is: a genuine reality that impacts the viability and longevity of both the hospital and the provider’s career. Being completely transparent about the financial implications of the measures is a great place to start. It is also important to keep your provider teams up-to-date on the way the healthcare industry is evolving so that the motivation behind things like patient satisfaction scores and CMS quality measures is clearer.

Set Measurable Goals and Make a Plan with a Timeline

Once your team trusts you, believes in your facility’s mission and vision and core values, and understands the necessity and impact of the metrics they are held accountable to, you are in a position to set goals and build a strategy that has legs. For optimal positive impact, I suggest engaging your clinical team as much as possible in goal setting and strategic planning. This can be achieved by including them in more departmental and interdepartmental meetings and always keeping them up-to-date with communications with hospital administration. A team that is engaged in the planning will be more engaged in the operational execution of the plan. Ensure the entire team is aware of the goals you have set, the strategy behind them, and your operational plan to achieve them. It is crucial to apply a timeline to your strategy and to keep the entire team up-to-date on your progress implementing the plan and achieving the goals.

Focus on Metrics Providers Can Control

When working with emergency department teams, a common complaint is that providers are being measured by metrics that they do not have full control over. It is true, an emergency department physician does not have control over the whole care environment like a family practice physician who works in a clinic might. However, there are some metrics that ED providers have significant control over, and these are the metrics we focus on. Examples include: Bed-to-provider times, provider-to disposition times, nurse-physician communication (which impacts patient experience greatly), and sepsis and stroke care times. When it comes to patient satisfaction scores we zero in on tracking the specific Press Ganey questions that can be impacted directly by providers (i.e. “Did the provider explain everything about your care?”). Providers who feel that they are measured by metrics they can directly impact are much more engaged than providers who feel they are measured by nebulous metrics influenced by factors mostly outside their control.

Give Providers Skin in the Game

That brings me to my final, and perhaps most influential strategy for shifting mindsets on quality and efficiency metrics: giving the provider team equity in their practice. When we develop goals for the department for metric improvement, we also create an agreement with the hospital to tie a portion of provider income to the metrics we are working to improve. Implementing a thoughtful incentive plan spurs significant improvements in provider engagement because providers feel a greater sense of ownership in their practice. It not only improves metrics but also reduces provider turnover and burnout.

Shifting mindsets to create a high-functioning emergency department team is about much more than setting metric goals. In fact, that is a very small part of the effort. Most of the meaningful and effective work is listening, aligning your team around a shared mission, educating your team on the importance of the metrics, and engaging the team in setting goals and creating a strategy to improve performance.

Teamwork Culture in Emergency Departments Improves Care Quality and Team Morale

Leaders building a brand-new rural community hospital in Texas asked me (along with some of my colleagues who now make up CareCulture’s leadership) to help them optimize their emergency department. The new facility was a fresh start, despite the fact that most of the doctors and nurses were familiar with each other and had been working in the same community for a long time. Most of their existing team members were entrenched in traditional, hierarchal methods of delivering emergency care. The hospital administration tasked us with establishing a culture based on teamwork, mutual respect, and a focus on patient needs. Because the team was deeply immersed in their long-established practices, shifting their approach was a formidable challenge.

I have served as medical director at a wide spectrum of emergency departments over the years—rural critical access hospitals and trauma centers alike—and every time the root cause behind the performance issues they face is their culture and the leadership style that perpetuates that culture. This department had a culture issue that was woven tightly into the traditional culture of healthcare delivery. It is one I felt strongly about unraveling: hierarchal, top-down leadership. As an alternative, I always encourage emergency departments to replace top-down management with team-based leadership that cultivates a safe environment for all team members to be empowered to speak up in the interest of better care for our patients.

When we arrived at this rural facility, we were seen as the “city folk”, outsiders from Dallas. The nursing staff and techs were anxious about our presence, assuming that we would follow the stratified approach to emergency department leadership to which they were accustomed. The leadership style depicted in the famous book, The House of God, in which attending physicians dictate orders while all other team members are expected to bow and nod their heads in agreement, carrying out their orders without question.

Inevitably, top-down leadership and the attitude that the entire ED staff exists to serve the medical director and attending physicians leads to conflict, unspoken frustration, and poorer care quality for our patients. When we started managing the new, small community hospital in Texas we took a different approach. Instead of dictating, we invited the nurses, techs, and administrative staff to the table and asked them how we could make their lives easier. We encouraged them to share their opinions and to question us (the physicians) if they saw a better way or had a question or suggestion.

It is a new way of viewing emergency department hierarchy. The team-based approach eliminates the feeling that nurses and techs exist to serve physicians and replaces it with the attitude that the entire team exists to serve each other to best serve the patient. This is not to say that the doctor will not have the final say on a course of action, but it does mean that the nurse or tech’s ideas are thoughtfully considered before making the final decision.

To shift the mindset of the team, we first speak with everyone on the team to discuss what is working well and what is not working. Any power dynamic between nurses and physicians needs to be broken down. We do this by creating regular opportunities for discussion and feedback, such as regularly scheduled all-hands meetings and an open dialogue during daily interactions. In the meetings, we make it clear that a nurse or tech questioning a physician is not just allowed, but expected. We expect to be held accountable. We impart the philosophy that we are servant leaders who do not just expect to be served, but are beholden to serving and respecting our colleagues as equally significant and influential members of the team—regardless of title.  

Nurses and techs are not the only ones who need to shift their mindset in order for this culture to take hold. Physicians must also feel comfortable and secure giving and receiving feedback and being questioned regularly and openly. Traditionally, some physicians may view being questioned by a nurse or tech as demeaning or a mark of failure. They may feel that because of their extensive training they know what is best. In turn, nurses may feel that it is disrespectful to question doctors. This new team-based, service-oriented culture enables physicians to set any pretense or power dynamic aside and prioritize what is best for the patient—no matter whose idea it is.

This culture change goes beyond the nurse-physician power dynamic, extending to EMS personnel, social workers and other professionals the emergency department regularly interfaces with. As part of our team-based approach, we encourage emergency department care providers to reach out—beyond the walls for the ED—to seek feedback and improve communication across the continuum of care. For example, at this particular hospital, EMS personnel who frequently brought patients to the ED were accustomed to being immediately interrupted by the doctor. This recurring behavior led them to immediately stop talking when a physician entered the room. As part of our management change, we encouraged EMS personnel to give a full report and encouraged our physician team to listen for the full report without questioning or interrupting. This approach worked, and more vital information was passed from the EMS personnel to the ED, allowing us to take better care of the patient.  

When this open, team-based approach takes hold, the entire team is more empowered and invested in the collective success of the department and hospital. Physician-nurse interactions are more open and positive. Communication between providers and patients improves. Team members are more excited about coming to work each day.

When we implemented this change at this newly rebuilt facility in rural Texas, we saw a notable improvement in the interactions between all emergency department providers and staff. Shortly after the opening of the hospital, several experienced nurses volunteered to take on more significant roles in the emergency department because their input was taken seriously, which empowered and inspired them to be more involved. The newer nurses were also more comfortable asking the doctors questions, which helped their understanding and improved the quality of care for the patients.

Taking a more open, lateral rather than hierarchal approach fosters a more nurturing, safe environment for physicians, nurses, techs, administrative staff, EMS providers, and other people who interface with the emergency department to openly share their ideas, which improves department efficiency, care quality, and patient experience as a whole.

6 Philosophies Forward-Thinking Emergency Departments Share

Emergency departments that embrace the below philosophies benefit from outstanding culture and in turn  high physician retention rates and leading performance metrics.

We are owners, not renters

Successful emergency departments engender a sense of ownership among the team by engaging them in formal and informal meetings, seeking and implementing their feedback, and rewarding their accomplishments.

We are here to serve

Strong emergency departments view all – from medical directors and physicians to nurses and techs – as important members of the team and they prioritize serving their team members so that they may better serve their patients. This means doing the extra thing to make life easier for every person you interact with, every day.

We are accountable

Thriving emergency departments consider every challenge and opportunity and consistently address issues rather than shifting blame or accepting the status quo. That means turning phrases such as, “I can’t do that. It’s not our policy...” and “that’s not my job…” on their heads and replacing them with constructive phrases like, “Let me see what I can do,” and “Let me find someone who can help.”

We are positive

Positivity breeds more positivity. Consistent positive communication across all roles within the emergency department makes it difficult to have a negative interaction with a colleague or a patient, which improves both patient satisfaction and provider burnout and turnover rates.

We communicate with respect

Improved efficiency, quality, and practice culture starts with better face-to-face communication at every interaction, from patient check-in, to patient hand-off, to admission, discharge, or transfer. Every interaction, no matter how high-stress should be positive, constructive, and respectful.

We are innovative   

The definition of insanity applies here: you cannot keep doing the same thing over and over and expect different results. Your ED must evolve to succeed. Part of innovating for the future is considering the department’s impact on the entire continuum of care. Overall, successful emergency departments ask “how can we do it better?” rather than holding on to, “that’s the way we’ve always done it.”

Adopting these philosophies can pay dividends in reduced provider turnover costs due to increased provider satisfaction, increased efficiency due to improved interdisciplinary relations, and more satisfied patients due to kind, respectful interactions and smoother patient transitions. These tenets contribute to a strong program culture, and by building a solid cultural foundation, you set the tone for lasting, tangible increases in patient and clinician satisfaction, positive community reputation, and quality and efficiency performance improvements across the board.

Culture Check Up: How to Assess Your Emergency Department Culture

Whether you are aware of it or not, your emergency department has a unique subculture within your organization. Hopefully the subculture is positive and harmonious. If there are elements of dysfunction begin by assessing your emergency department’s current strengths, weaknesses, and opportunity areas. Outlined below are steps to follow to assure your emergency department team is united and headed in a direction that mutually benefits the providers, staff, hospital or health system, and the patients and community you serve.

1. Identify key stakeholders

When working to assess the culture of the emergency department, it is crucial to include everyone who works within or interfaces with the emergency department in your assessment. This includes:

• Hospital administration

• Hospital leaders and community providers who interface with the emergency department

• Physicians and Advanced Practice Providers

• Nurses and technicians

1. Have face-to-face conversations with key stakeholders

Once you have identified stakeholders, talk with them to clearly understand their vision, needs, and goals. The act of asking for input is itself a great opportunity to promote a culture where everyone feels valued. Start by asking:

• What do you love most about your job?

• What would you change that would make coming to work each day a more positive experience?

• How does/can the emergency department contribute to achieving your goals/meeting your needs?

1. Summarize key challenges and opportunities

A collective review of answers to the questions in the previous section can illuminate core strengths and weaknesses of department culture. After you have this information, natural themes will emerge around which workflows, processes, and training need to be improved to promote a more satisfied staff and in turn safer, more cost-effective, efficient patient care. Your summary should include a full assessment of the following:

• How does the community perceive the emergency department?

• What are the abilities of the current clinical staff?

• What is important to each stakeholder and are priorities aligned?

• Physician turnover, how often are providers leaving and why?

• How are physician relations with APPs, nursing staff, and techs?

• What defines success?

• What is the general attitude among staff?

• Does the clinical staff feel supported?

• Does the clinical staff feel invested?

• What are the primary communication issues within the department?

• Where does efficiency/throughput break down? Why?