Medical Staff

Recognizing Exemplary Care

Medical Staff Leader Insider, March 8, 2012

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“We are all adults. We don’t need gold stars for doing our job!” Those were the surprising words from a member of a new peer review committee as we discussed the practice of recognizing exemplary care. The discussion persisted for almost 20 minutes of valuable committee time as he strongly voiced his objections.

What was surprising is that most medical staffs are looking for more ways to give physicians positive feedback so that they view peer review as balanced rather than punitive. To facilitate a shift in attitudes, this medical staff redesigned its peer review approach. As part of the redesign, the medical staff approved the use of exemplary care letters when practitioners provide exceptional care under difficult clinical circumstances.  Yet, as we trained the physician reviewers on the committee how to nominate exemplary practices, this physician felt that recognizing exemplary care was not needed and was quite opposed to it. Was he right?

For those of you unfamiliar with the exemplary care recognition approach for case review, it is based on the principle that just because a case is identified for review does not automatically mean that the physician providing care could have done anything different to prevent or mitigate the outcome.  That is why the case requires peer review. Taking that concept one step further, reviewers often find that either the physician under review, or another caregiver, provided some exceptional, even heroic, care.  To ignore those efforts reinforces a culture that only looks at the negative aspects of peer review.

To facilitate the use of this approach, the Greeley case review rating form has a section for exemplary practice nominations. This section is separate from the three-level rating system for overall physician care (i.e. care appropriate, questionable, or inappropriate). When the reviewer notices exemplarity, he or she briefly describes why. If the physician under review provided exemplary care, the reviewer should nominate him or her only if the overall care was rated appropriate. However, reviewers can nominate other physicians or practitioners involved in the case who provide exemplary care no matter what the rating is for the physician under review.

Committees that recognize exemplary care discuss nominated practices just as it would negative aspects of the case. If a committee agrees that care was exemplary; it sends a letter to commend the individual. Unlike some kids T-ball or soccer leagues, the goal is not to give out trophies just for participating; it is to recognize exceptional efforts.

Let’s get back to our committee meeting. The committee member’s objections were based on two issues. The first is that physicians don’t need pats on the back. The reality is that this not true for most individuals, physicians included. In the Greeley Medical staff culture survey, which we have performed for over 200 hospitals, appreciation is the lowest rated of the 10 cultural attributes measured.  Physicians may know that they are good, and their patients may thank them, but hearing it from their colleagues is a special reward.

The second issue raised by the physician was that this practice is unfair. Because cases are selected for adverse outcomes, this approach ignores all the exceptional care provided when things turn out well. Although most physicians would like to have the ability to indentify exceptional care whenever it occurs, given the limited amount of time they can contribute to peer review, it seems a shame to ignore exceptional care when a physician sees it just because he or she is unaware of it in other circumstances.

How did this story end? The medical staff leaders decided to stay the course and continued to recognize exemplary care. I hope I will get the chance to meet this physician again after the practice has been in place for a while to see if he has changed his mind.

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