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Background: Physicians should be engaged in quality-improvement activities to make the systems in which they work safer and more reliable. However, many physicians are still unable to contribute to patient safety initiatives that lead to safer, high-quality care for their patients., Objective: To survey 10 high-performing hospitals in the USA to determine how they engage their physicians in quality and safety., Design: Qualitative study that used site visits and a semistructured 20-question interview., Setting: Ten high-performing US hospitals were chosen from the 2010 US News and World Report Best Hospitals and the Leapfrog Group on Patient Safety., Participants: Forty two interviews were conducted with forty-six quality leaders including CEO's, Chief Medical Officers, Vice Presidents for Quality and Safety and physicians., Measurements: Site visits and in-person interviews were conducted during 2010-2011. The interviews were transcribed and coded using the constant comparative method for further analysis by the team., Results: The authors developed a six-point framework for physician engagement in quality and safety as a constellation of the best strategies being used across the country. The framework consists of engaged leadership, a physician compact, appropriate compensation, realignment of financial incentives, data plus enablers and promotion., Limitation: The qualitative design and the small number of hospitals surveyed mean that the results may not be generalisable., Conclusion: There remain many ongoing barriers to physician engagement in quality and safety. Some high-performing hospitals in the USA have made significant improvements in engaging their physicians in quality and safety. The proposed framework can assist organisations in the development of strategies to engage physicians in quality-and-safety activities.

A 69-year-old woman with several medical problems believes that she is allergic to generic medications. She frequently conflicts with her long-time primary care physician, who, as required by the patient's insurance coverage, refuses to prescribe brand-name drugs when generic alternatives are available. This conflict intensifies to a crisis when the patient develops life-threatening problems and still will not take prescribed generic medications. The presentation of this real case is accompanied by a discussion of the ethical dilemmas of the patient's physician, who must weigh the interests of a patient who clings to beliefs that the physician thinks are unfounded against the interests of a just rationing program and the broader population it serves.

A review of payment-for-performance initiatives is presented. Topics include origins, goals and rationale, advantages and disadvantages, and prototypical systems such as Bridges to Excellence, the Integrated Healthcare Association's Physician Payment Program, and the Anthem Blue Cross and Blue Shield Plan. Payment for performance means a doctor would receive a financial incentive for improving the quality of care they provide.

We believe that reliably offering Hope should be one of the goals of the therapeutic relationship between clinician and patient. Establishing Hope as a target outcome creates opportunities for both patients and clinicians to find meaning in their journeys. This article defines Hope in a new way by quantifying Hope as the delta or increase in one's belief that a future positive state can be achieved. Though prior conceptual models of Hope have focused nearly exclusively on an individual's own agency and competence to achieve goals, we particularly emphasize the role of Other—specifically, that of the clinician—in promoting Hope for patients. We recommend a Hope Checklist for clinicians that incorporates (1) the process of eliciting and clarifying patient goals, (2) conveying the intent and ability to help, and (3) identifying realistic pathways forward with the specific intent to maximize patient confidence in the potential to achieve meaningful positive outcomes. [ABSTRACT FROM AUTHOR]

The article offers information on transforming culture in health care. It mentions that understandings of culture usually focus on norms, values, interactions, and beliefs; and also mentions that physicians develop models of group autonomy and self-regulation rather than clinging to traditional models focusing solely on the individual.

That said, any performance data can be misused, and I believe that individual physicians should never be presented with financial incentives for patient experience data from their own patients. Comment & Response B To the Editor b A recent Viewpoint[1] made important points about how duress for physicians can be worsened if patient experience data are misused, but in doing it so misinterpreted or misrepresented available data. [Extracted from the article]

The health care marketplace is increasingly being driven by competition on value for patients -- that is, meeting their needs as efficiently as possible. Academic medical centers must adapt to this shift through the development of true strategies aimed at creating value, as opposed to trying to deflect the pressures of competition through tactics such as merging with competitors. True strategies require clarity on what the organization is trying to do for whom, and how the organization is going to be different from its competitors. Six key questions are described and discussed: 1) What is our goal? 2) What businesses are we in? 3) What set of conditions shall we compete in? 4) How will we be different? 5) What synergies can be created across our sites? and 6) What is our appropriate density and scope? Academic medical centers have been the crown jewel of health care for the United States and, indeed, the rest of the world. Their research, teaching, and patient care missions all command respect, and their halls are filled with representatives of industry interested in scientific advances; trainees seeking expertise; and patients hoping for relief of their suffering -- or at least peace of mind that all opportunities for improvement of health have been exhausted. Despite obvious "demand" for what academic medical centers have to "sell," the evolving health care marketplace poses existential threats to academic medical centers, causing many such organizations to wonder what their role should be -- or if they will even be in existence. The threats are indeed real, and they cannot be overcome by reminding the public of the noble missions of academic medical centers. Instead, academic medical centers need to rediscover the meaning of strategy, which always requires choices that are politically challenging. But organizations that can develop a true strategy and make those difficult choices have an excellent chance of thriving in the new marketplace -- because, in fact, academic medical centers have some advantages that their competitors lack in the struggle for market-share. [ABSTRACT FROM AUTHOR]

The author reflects on the growing popularity of non-visit medical care in the U.S. He cites the significant progress of nonvisit approach initiated by Kaiser Permanente in which 52 percent of its more than 100 million patient encounters the virtual visits. The author also asserts that physicians are starting to use virtual system, which could be further improved if health systems were designed with such care as explicit goal.

Evaluation of physician performance is increasingly based on patient satisfaction. However, few data are available regarding the extent to which individual physician profiles might be influenced by factors such as whether a physician's practice is open or closed. We evaluated whether panel status (whether or not a physician is accepting new patients) is associated with patient satisfaction with their primary care physician (PCP).Cross-sectional analysis of patient satisfaction surveys. Surveys were available for 1750 patients cared for by 69 PCPs. Patient satisfaction with their PCP was determined based on a composite of six questions derived from the Medical Outcomes Study. We used Generalized Estimating Equations to adjust for physician level variation.Patients of closed-panel physicians were more likely to rate their satisfaction with the provider as‘Excellent’ or‘Very Good’ compared to patients of open-panel physicians (78% vs. 69%,P < 0.0001). After adjusting for satisfaction with the practice site, provider years in practice, managed care coverage, provider productivity, and patient race, the association between a closed panel and satisfaction remained significant (odds ratio 1.60, 95% confidence interval 1.10–2.31).Individual physicians’ patient satisfaction data are confounded by factors not likely to be adjusted for in available profiles. After adjusting for other variables, physicians with closed panels still had better patient satisfaction compared to physicians with open panels. Further research is necessary to determine if panel status might also confound patient satisfaction. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness of housestaff physician reporting as a method for identifying adverse events on a medical service and to compare the physician reporting mechanism with a retrospective record review mechanism.Setting: Medical service of an urban, university-affiliated teaching hospital.Design: Concurrent physician reporting mechanism using the hospital electronic mail system compared with a retrospective record review using a screening mechanism followed by structured, implicit physician review of the record.Patients: All 3146 admissions to the medical service from 13 November 1990 to 14 March 1991.Results: The housestaff physician reporting method identified nearly the same number (89) of adverse events as did the record review (85). However, the two methods identified only 41 of the same patients (kappa = 0.52). No statistically significant clinical or socioeconomic differences occurred between the patients identified as having had an adverse event, using the two reporting methods (physician versus record review). The housestaff did report statistically more preventable adverse events (62.5% compared with 32%; P = 0.003). The physician reporting mechanism was also less costly (approximately $15,000 compared with $54,000).Conclusion: An adverse event identification strategy based on physician self-referral uncovers as many adverse events as does a record review and is less costly. In addition, physician-identified events are more likely to be preventable and, thus, are targets for quality improvement. [ABSTRACT FROM AUTHOR]

In this article, the author expresses his views on the changes in the payment system for health care delivery in the U.S. in 2009. The standard policy is that organizations get paid for transactions and not for producing outcomes. Due to such changes, hospitals have started to offer incentives to minimize readmissions and several health care provider systems have implemented pay-for-performance incentives which are based on clinical results. The author comments on the changes in responsibilities for physicians and board members.

A response from the author of the article "Certifying the Good Physician: A Work in Progress" in a 2014 issue is presented.

In this article, the authors look at the issues related to the 2010 Affordable Care Act (ACA) which is implemented under the U.S. President Barack Obama administration in the U.S. They mention that hospitals, health care centers, and physicians are consolidating into accountable care organizations (ACOs) to address new payment contracts after ACA adoption, which reward lower spending and higher quality. They discuss the delivery system reform phase of the health care reform ACA which focuses attention on the culture of medicine. They suggest several domains for modern physician organizations to embark on delivery system reform including leadership, incentives and patient satisfaction.

Editorial. Supports the methods of implementing guidelines in clinical practice used by Stiell et al as reported in same issue. The way the Ottawa Knee Rule was introduced to physicians, including multiple dissemination tools and patient information sheets; Effective implementation of guidelines requiring clinical leaders to be managers not just teachers.

The article introduces a new series of review articles focusing on clinical practice. The series is started by the periodical with the aim of providing physicians involved in patient care with information about problems that they confront on a daily basis, in a format that makes the information clear and accessible. It is reported that the articles will have a consistent format, to make it reader's friendly.

The article discusses the flaws of the systems and processes of providing health care. It presents the case of a 53-year-old woman who underwent a splenectomy after a motor vehicle accident 10 years prior to being diagnosed with pneumococcal sepsis. The woman filed a law suit against her primary care physician which was later on settled. An analysis of the case was carried out to prevent future procedural and human errors in providing care.

Despite the growing use of computed tomographic angiography (CTA), the effect on patient management is less clear. We sought to determine the perceived usefulness of the results provided by CTA and to assess whether and how it influences patient management. Comprehensive prospective data were collected from 184 consecutive patients who presented for clinical CTA for the evaluation of coronary artery disease from March to July 2008. In addition, a detailed survey was sent to each referring physician for each patient examined to assess whether they found the results of the CTA useful and whether it had any influence on subsequent patient management. Of 184 CTA examinations, which had been ordered by 82 different providers, 108 surveys (59%) were completed by 53 different physicians. No significant differences were found in either the patient or provider characteristics for the completed versus noncompleted surveys. Of the 184 CTA examinations, the severity of coronary disease detected by CTA was severe for 26%, mild to moderate in 47%, and not present in 27% of the patients. Clinicians considered the test results to be useful in virtually all cases and thought the results led to significant risk reclassification in 58% of the patients. If CTA had not been available, the clinicians indicated that they would have ordered an invasive test for 46% of the patients and noninvasive tests for 32%. After CTA, changes in medical therapies were made for 31%, invasive angiography was planned for 19%, and noninvasive testing was scheduled for 6% of the patients. In conclusion, of 53 different referring clinicians from different medical specialties, CTA was considered to almost always be useful; however, the effect on subsequent medical management was more variable. [Copyright &y& Elsevier]