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Safety and quality suffer under strained systems, says survey of doctor executives

A survey of physician leaders said money and communication problems are among major barriers to providing good patient care. But there were some bright spots.

By Damon Adams — Posted July 9, 2007

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Doctors say there are too many obstacles to improving quality care and patient safety.

A lack of money and resources, poor communication among health care professionals and a desire to keep the status quo are among the biggest hurdles physicians struggle to overcome. When it comes to implementing quality and safety initiatives, many doctors fight to find the right balance between what's best for their patients and what's best for the health care organization.

That's according to a new national survey of 1,155 physician leaders the American College of Physician Executives conducted. Meanwhile, a new poll of 300 California doctors found that physicians are concerned about patient care largely because administrative burdens leave them less time to spend with patients.

The surveys add to the body of evidence quantifying doctors' growing frustrations with the health care system.

"Physicians are busier than ever trying to deal with all of the pressures on them," said Steven Tremain, MD, director of system redesign at Contra Costa Regional Medical Center in Martinez, Calif., who is familiar with the ACPE survey. "There is waste everywhere, from inefficiencies to work flow. We can get better outcomes and do it more efficiently."

The ACPE in February sent the quality-of-care survey to its members, who include physicians and physician administrators working in hospitals, group practices and other health care organizations. The questionnaire asked about patient safety and quality issues and the barriers to improving those areas. Findings were published in the May/June issue of the group's journal, The Physician Executive.

Ninety percent of physicians cited a lack of resources and money as an obstacle to providing quality care and patient safety, while 89% said communication among physicians, nurses and others was a barrier. Most surveyed doctors also cited obstacles such as patient compliance and awareness of healthy habits, a resistance to change and physician reluctance to use evidence-based medicine.

Among other findings:

  • 59% of doctors struggled to strike an appropriate balance between what is best for the patient and what is best for their health care organization.
  • 53% said decisions about quality and safety initiatives sometimes or frequently favored the organization rather than what they believed was best for the patient.
  • 33% said cost was the primary focus in allocating the resources to quality and safety in their organization.

Physician leaders also listed problems that contribute to inefficiency and hinder the ability to deliver safe, quality care. Those include medical errors, overuse and underuse of care, patient flow problems and complications from procedures.

About half of respondents said employees in their organization feared reporting errors or safety hazards because of repercussions or being fired.

Administrative woes

In a California Medical Assn. survey of 300 of the state's doctors, 38% said the quality of patient care has worsened since they started practicing medicine. Administrative issues frustrate doctors, and 85% said decreased time with patients affects patient care.

"Physicians are feeling beleaguered by the increasing administrative burdens brought on in the last several years that are more onerous and more time consuming," said CMA President Anmol S. Mahal, MD, a gastroenterologist in Fremont, Calif. "What physicians are complaining about the most is that these administrative burdens are taking time away from patients."

But there are some encouraging signs in both surveys.

The California poll, released last month, found that 81% of the state's physicians would choose to become doctors again, despite knowing what they know now. And most doctors said helping patients is the most satisfying part of being a physician.

In the ACPE survey, nearly all doctors said physicians in their organization support quality and patient safety improvement projects, and 77% said their organization is doing something to correct such major problems as medical errors and patient flow delays.

"Getting the best possible outcome for a patient is everybody's business," said Alan H. Rosenstein, MD, vice president and medical director of the West Coast office of VHA Inc., a national health care alliance.

Some physician leaders said doctors and administrators need to do a better job communicating with each other about quality and safety issues. They should assess what obstacles they face and how best to address them together, they said.

Steven Safyer, MD, senior vice president and chief medical officer of Montefiore Medical Center in Bronx, N.Y., said patient care at Montefiore has improved in part because of an integrated system that lets doctors access patient records anywhere in the system. "We're not fragmented," he said.

St. Louis internist Tom Doerr, MD, who works in a group practice, said electronic medical records and other changes can reduce obstacles and increase quality patient care.

"We need to move beyond discussion of the symptoms to solutions," Dr. Doerr said.

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ADDITIONAL INFORMATION

What's standing in the way?

A survey of 1,155 physician executives asked about the most common obstacles to high-quality health care and patient safety initiatives.

Issue Sometimes an obstacle or a major obstacle Not an obstacle
Patient compliance and awareness of healthy habits 93% 7%
Lack of resources/money 90% 10%
Clinician communication and culture 89% 11%
Physician resistance to use evidence-based care 88% 12%
Desire to maintain status quo 87% 12%
Insurance companies' practices 80% 20%
Federal government policies 80% 20%
Fear of reporting quality and safety problems 77% 22%
Administrative culture that doesn't support quality/safety initiatives 58% 41%

Note: numbers have been rounded.

Source: 2007 Quality of Care Survey, American College of Physician Executives

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In their words

In a national survey, physician executives shared comments about quality care and patient safety. Here is what some doctors said:

  • "There's not enough time and not enough money to do all that we would like to do."
  • "Physicians are struggling to maintain their income with declining reimbursements. This leads to a focus toward their own practice just to keep up with the continued changes."
  • "We closed our inpatient rehab unit because it was losing money. We are considering eliminating our outpatient counseling program and our neonatology program for the same reasons. In both cases, patient care will suffer."
  • "Pressure for 'customer satisfaction' instead [of] what is actually appropriate for the patient."
  • "Admitted patients are left in the emergency department for extended periods of time. This causes dangerous delays in the care of newly arriving patients. The organization fails to allocate adequate resources to care for admitted patients in appropriate inpatient settings."
  • "We sometimes set our clinic hours for our convenience as opposed to the needs of patients. We also understaff our ED. It saves money for us, but decreases access for patients and results in prolonged wait times."
  • "Incentive is based purely on volume of patients seen per day. There is no objective measure of quality of care."
  • "Financial burden of some quality/safety measures leads to acceptance of lesser goals."
  • "Lack of interest and lack of adequate funding. Indifference and/or sense of hopelessness on the part of staff, including physicians."
  • "Simply ... overwhelming!"

Source: 2007 Quality of Care Survey, American College of Physician Executives (link)

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