Core Leadership Competencies

Clinical Excellence

Creating clinical cultures known for excellence in the delivery of high-quality patient care

Attributes

• Top quartile patient satisfaction scores
• Top quartile faculty engagement scores
• Top quartile patient outcome national benchmark scores (appropriate by specialty)
• Established plan for continuous quality and patient safety improvement
• Documented provider of choice
• Ongoing effort to maintain or achieve US News Ranking(s)

Assessment Questions

• What clinical quality measures do feel are most important for your program?
• Do these measures align with your hospital partners.
• What are the clinical strengths and weaknesses of your program? Provide 3-5 steps for improving each weakness.
• Do opportunities exist to build clinical expertise and competency?
• What metrics, rating services, … do you utilize to determine patient satisfaction, quality of patient care and position in marketplace?
• How do you assure that your clinical programs are equitable?
• Describe a quality improvement initiative you successfully led for your program.
• How would you rate the safety of your care delivery?

 

Pediatric Leadership Insight

Academic medical centers (AMC) have usually enjoyed the reputation as providers of innovative, evidence-based, superior clinical care. This has been especially true in institutions that deliver pediatric care, most likely because of their focus on the special clinical conditions and needs of children and their families.  Several challenges exist however, in insuring that such high quality care is actually being delivered.  Those challenges include:

1. How to measure clinical excellence;
2. How to construct quality improvement activities to identify and correct measured deficiencies;
3. Potential competing priorities of faculty members in providing patient care, teaching, and producing scholarship;
4. Maintaining a high level of performance in each of those latter three domains; 5. maintaining equitable reward systems for faculty who provide high quality clinical care.

These challenges and others can potentially detract from the overall goals of AMC’s and healthcare systems to provide the best clinical care possible, especially as the US healthcare system becomes more complex and competitive. Thus, these challenges must be recognized, managed, and mitigated in order to optimize the clinical success and the educational value for students and trainees.

• Measuring clinical excellence – quality metrics in healthcare are often cumbersome to measure and frequently imprecise. This is especially true for pediatric AMC’s that treat unusual or relatively infrequent medical and surgical conditions, or that treat a relatively smaller number of patients compared to institutions treating adults. Consequently, proxy measures for clinical excellence are often used that include things that are more easily measured, such as numbers of patients treated, clinical revenue, or relative value units (RVU). Outcomes measurements are far more difficult to define and quantitate in pediatrics because of smaller numbers, relatively low mortality for most conditions, and relatively infrequent complications. So again, proxy outcome measurements are sometimes proposed, such as hospital lengths of stay, resources used, or overall charges billed; few clinicians consider those proxies as adequate measures of their quality of care.

One improvement in the measurement of pediatric clinical outcomes is the development of several collaborative, national, specialty-specific databases (examples include the Vermont Oxford Neonatal database, the American College of Surgeons Peds-NSQIP, the Extracorporeal Life Support Organization database, United Network of Organ Sharing, etc.).  The data in such databases is usually high quality and provides a comparison of one’s own institution to peer institutions. These data are often capable of adjusting for risk as well, an important factor particularly for AMC’s that frequently end up treating higher risk patients. In addition, these data can potentially identify institutions with demonstrated best practices , which when shared with other database participants can lead to widespread process and outcome improvements.

Unfortunately, the costs associated with these databases are significant, and when multiple clinical leaders each ask for their respective specialty-specific databases, the collective costs can be hundreds of thousands of dollars per annum for each AMC. Given these high costs, many AMC’s limit their use of such collaborative databases to clinical programs that are of high risk, in regards to morbidity, institutional reputation, or resource utilization.  This limitation often means that many other clinical programs will not have reliable data to verify clinical outcomes.

One measurement of outcome that is frequently used is patient (or family) satisfaction.  As an overall assessment of how well an institution is meeting their patients’ needs, this is a sound metric. Where it is possibly less accurate is at the individual faculty or provider level. Physicians often lament that the patient experience scores are impacted by “system issues” that are out of their control – things like parking, waiting times, staff interactions, etc. Nevertheless, comparison among physicians in a similar practice or specialty at the same institution can help identify both positive and negative outliers; lessons can then be learned from the former and the latter can be coached or assisted to perform at a higher level.

When a lack of good outcome measurement tools exists for a specialty program, process metrics can be substituted. Examples might be faculty-specific ordering of  diagnostic tests or medications for specific index diagnoses, or compliance with clinical pathways and protocols.  Other process measures include timeliness of communication to referring primary care physicians. While such process measures might not link directly to outcomes, there is usually a correlation.

 

Additional Resources

Articles [to come]
Books [to come]