Measuring quality and efficiency of individual doctors

This week a Consultant colleague and I walked to two other wards to see patients that were coded under him but were on specialty wards.  It turned out that both patients were under the care of specialty teams and this was just coding that needed updated.  Although it was important that we checked to ensure someone was looking after the patients it did take some time to do and as we walked back to the AMU we discussed efficient use of Consultants’ time.

Often now Consultants share secretaries or complain of inadequate secretarial support.  They may be spending time taking and typing minutes for their own meetings.  They may be doing simple data entry as part of research and audit projects.  They may be managing their own diaries and arranging venues for meetings and teaching.  Is this a good use of their time?  Before we can answer that we need to decide what the unique contribution of Consultants is.  What value do they add that other less-well-paid staff cannot add?  They provide clinical expertise, advanced decision-making and risk management.  They provide unique value when applying that expertise, decision-making and risk management to individual patients.  They also provide unique value when providing clinical leadership or applying their skills and expertise to quality improvement projects.

It may cost more money to relieve Consultants of low-value-added tasks by employing others to do them but what’s the alternative – to let them work less efficiently?  This is why senior managers and Directors often have PAs.  It is accepted that their unique contribution and the reason they receive their higher salary is for their leadership, decision-making, expertise and risk management.  It is therefore more efficient to employ someone else to manage their diary, do their filing, type their letters et cetera, so that they can concentrate on adding the value only they can add.  Why then do I hear so many Consultants complaining that they have inadequate admin support and that their pleas to managers fall on deaf ears?

For a different view of using doctors’ time efficiently in a clinical setting I will reflect on my experience shadowing a Family Physician in Minnesota, USA.  I found it interesting that he had 3 or 4 consulting rooms and 2 nurses working with him.  The nurses brought the patients from the waiting room to one of the consulting rooms and took a brief history, addressed health promotion issues and performed basic observations.  A flag system above the door was used to signal which stage of the process the patient was at and the physician would see the next patient ready for him.  With each patient he provided the unique value only a physician could add.  If the patient needed blood test he would write an order, put up a flag to alert the nurse and move to the next patient.  Once the blood results were available (they had a lab analyser in the practice) the nurse would put up a flag to signal this to the Physician so he could consult with the patient again with the results of the tests.  I was fascinated by this very different way of doing things compared to primary or secondary care clinics here in the UK.  I asked my host about this and he explained simply that it meant a better quality service for patients and was more efficient.  They had done the sums, and the increase in Physician efficiency more than covered the cost of the additional nurse (he always had one nurse working directly with him before this).

I found it interesting that in the healthcare system I observed in Minnesota, quality and efficiency are measured at the level of the individual doctor.  This allows interventions aimed at improving quality and efficiency at the individual doctor level to be measured.  Can we do this in the UK?  Should we do this?

 

Raising Concerns

This week I had to deal with raising and acting on two different concerns.  Both were in my capacity as a medical manager.

Anyone who has thought about raising a concern or has actually done so will know that it’s not easy.  You think about it a lot and may seek advice from a trusted peer or senior colleague, but in the end you’re the one with the concern and you’re the one that has to raise it.

I’ve found that people don’t react well to concerns being raised.  Some react by trying to play down the concern and telling you that you’re overreacting.  Some get angry about it.  But thankfully some are also supportive.

I wouldn’t like anyone reading this to be put off raising a concern because of the experiences I’ve described.  Looking back I don’t regret raising any of the concerns I’ve raised.  We just need to see a change in culture around raising and acting on concerns and this is more likely to happen if people continue to raise them appropriately.

I now keep copies of Good Medical Practice, Leadership and management for all doctors, and Raising concerns in the letter tray beside my desk for reference.