The multiple facets of physician The multiple facets of physician decision-making under uncertaintydecision-making under uncertainty
Katharina Janus, Ph.D.Katharina Janus, Ph.D.Harkness Fellow in Health Care PolicyHarkness Fellow in Health Care Policy
Department of Health Policy and ManagementDepartment of Health Policy and Management
Columbia University, New YorkColumbia University, New York
Orlando, June 2007Orlando, June 2007
OverviewOverview
Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and
practice in the U.S. and Germanypractice in the U.S. and Germany
1
10
100
1,000
10,000
100,000
1,000,000
Untrustworthy Quality of CareUntrustworthy Quality of Care
U.S Airline flight fatalities/U.S. Industry Best of Class
Airline baggage handling
1(69%)
2(31%)
3(7%)
4(.6%)
5(.002%)
6(.00003%)
Overall Health Care Quality in U.S.
(Rand Study 2003)
IRS Phone-in Tax Advice
NBA Free-throws
Sources: modified from C. Buck, GE; Dr. Sam Nussbaum, Wellpoint; & Mark Sollek, Premera
level (% Defects)
Def
ects
per
mil
lio
n
∑
Fair Reliability
High Reliability
Long-Term Goals
Short-Term Goals
Foundation
Build Trust / CollaborationBuild Trust / Collaboration
Structure / ProcessStructure / Process
OutcomesOutcomes
ImproveImproveMember Health Member Health
ValueValue
Quality Vision for P4P Programs in the U.S.Quality Vision for P4P Programs in the U.S.
Source: Nussbaum P4P Summit 2006
Limitations and challenges of P4PLimitations and challenges of P4P
Ceiling effects (high versus low performers)Ceiling effects (high versus low performers) Organizational scale (small practices)Organizational scale (small practices) Costs (too early to tell???)Costs (too early to tell???) Quality (some positive evidence…)Quality (some positive evidence…) Caveats (selection bias, definition of Caveats (selection bias, definition of
measures, loss of holistic approach to care, measures, loss of holistic approach to care, socio-demographic fine-tuning)socio-demographic fine-tuning)
Janus, K., Brown, L.D. (2007), Medicare as Incubator for Innovation in Payment Policy, Journal of Health Politics, Policy and Law, vol. 32, no.1: 293-306.
A new approach is needed…A new approach is needed…
BecauseBecause specialties are faced with significantly specialties are faced with significantly
different decision-making situations, have different decision-making situations, have different cultures and, thus, respond different cultures and, thus, respond differently to incentivesdifferently to incentives
a large part of medical decision-making does a large part of medical decision-making does not refer to routine treatment decisions, but not refer to routine treatment decisions, but rather to adhoc situations that are not rather to adhoc situations that are not standardizable and underlie a high degree of standardizable and underlie a high degree of uncertaintyuncertainty
Because one size does not fit all!Because one size does not fit all!
OverviewOverview
Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and
practice in the U.S. and Germanypractice in the U.S. and Germany
ObjectivesObjectives
What are the challenges of a physician operating under high What are the challenges of a physician operating under high uncertainty in a system?uncertainty in a system?
Are there Are there general decision-making patternsgeneral decision-making patterns of physicians in of physicians in case of unexpected events and what do they look like?case of unexpected events and what do they look like?
How do physicians How do physicians manage prospectivelymanage prospectively uncertainty and the uncertainty and the potential for error in their daily work life?potential for error in their daily work life?
What is the role of informal organization (e.g. event What is the role of informal organization (e.g. event discussions in the hallway) when discussions in the hallway) when dealing with unexpected dealing with unexpected eventsevents? Could/Should it be more formalized and structured?? Could/Should it be more formalized and structured?
Building on the derived decision-making patterns, how can the Building on the derived decision-making patterns, how can the ‘unpredictable’ be made more ‘predictable?’ What do ‘unpredictable’ be made more ‘predictable?’ What do ‘guidelines’ for unexpected events look like? What is the role ‘guidelines’ for unexpected events look like? What is the role of the human and what is the role of the system component in of the human and what is the role of the system component in these guidelines? How can we incentivize these guidelines?these guidelines? How can we incentivize these guidelines?
How can the strategies be implemented?How can the strategies be implemented?
OverviewOverview
Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and
practice in the U.S. and Germanypractice in the U.S. and Germany
MethodologyMethodology
Physicians from four specialties (surgery, general Physicians from four specialties (surgery, general internal medicine, anesthesiology and psychiatry) have internal medicine, anesthesiology and psychiatry) have been recruited for qualitative interviews at New York been recruited for qualitative interviews at New York Presbyterian Hospital and Weill/Cornell Medical Center.Presbyterian Hospital and Weill/Cornell Medical Center.
These four specialties represent a useful continuum for These four specialties represent a useful continuum for the degree of treatment processes that are considered to the degree of treatment processes that are considered to be ‘routine’ and non-routine.be ‘routine’ and non-routine.
Interviews were conducted face-to-face and were tape-Interviews were conducted face-to-face and were tape-recorded, transcribed and evaluated using a content recorded, transcribed and evaluated using a content management software.management software.
40 interviews are currently in the database. Further will 40 interviews are currently in the database. Further will follow.follow.
OverviewOverview
Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and
practice in the U.S. and Germanypractice in the U.S. and Germany
Uncertainty in decision-making versus Uncertainty in decision-making versus frequency of events across specialtiesfrequency of events across specialties
Frequencyof UnexpectedEvents
Uncertaintyin Decision-
Making
Anesthesia Surgery Internal Medicine Psychiatry
Stages of decision-making under Stages of decision-making under uncertaintyuncertainty
ProspectiveDecision-
Making
ActualDecision-
Making
RetrospectiveDecision-
Making
HumanComponent
Learning Support Reporting
SystemComponent
Prospective decision-makingProspective decision-making
ResourcesResources Articles, textbooks and the internetArticles, textbooks and the internet Colleagues and advisorsColleagues and advisors Equipment and pharmaceuticalsEquipment and pharmaceuticals Patient information and patient engagementPatient information and patient engagement
Reflection and experienceReflection and experience Risk assessment and prioritizingRisk assessment and prioritizing Acceptance of the “Random“Acceptance of the “Random“
Actual decision-makingActual decision-making
ResourcesResources Articles, textbooks and the internetArticles, textbooks and the internet Colleagues and advisorsColleagues and advisors Equipment and pharmaceuticalsEquipment and pharmaceuticals Patient information and patient engagementPatient information and patient engagement
Reflection and experienceReflection and experience Prioritizing under constraintsPrioritizing under constraints StressStress
Retrospective decision-making – Retrospective decision-making – how to deal with eventshow to deal with events
Formal processes for the unexpectedFormal processes for the unexpected Informal processes for the unexpectedInformal processes for the unexpected
Informal human interaction in generalInformal human interaction in general Physician culture in particularPhysician culture in particular
Blame/shameBlame/shame AccountabilityAccountability Reciprocity/ mutual protectionReciprocity/ mutual protection DetachmentDetachment Openness to failureOpenness to failure
System Factor – example MERSSystem Factor – example MERS(Medical Event Reporting System)(Medical Event Reporting System)
General reporting obligation (self/professionalism, patient, organization)General reporting obligation (self/professionalism, patient, organization) Incentives for reporting or not reportingIncentives for reporting or not reporting
AnonymityAnonymity BenchmarkingBenchmarking Connectivity and work process integrationConnectivity and work process integration CostCost CultureCulture Definition of eventsDefinition of events External professional organizationExternal professional organization Feedback/ Information accessFeedback/ Information access Immediate staff/technical supportImmediate staff/technical support LitigationLitigation Medical trainingMedical training Monetary incentivesMonetary incentives Organizational accountabilityOrganizational accountability Paperwork/timePaperwork/time Personal accountabilityPersonal accountability Threats by the organizationThreats by the organization Usability/tutorialUsability/tutorial
Reporting value for specialtiesReporting value for specialties
OverviewOverview
Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and
practice in the U.S. and Germanypractice in the U.S. and Germany
Implications and LearningsImplications and Learnings
Before designing incentive systems we have to Before designing incentive systems we have to understand physician decision-making.understand physician decision-making.
Managed care (Standard Operating Procedures) Managed care (Standard Operating Procedures) does not apply to decision-making under does not apply to decision-making under uncertainty.uncertainty.
But: Unexpected events derive from intrinsic But: Unexpected events derive from intrinsic uncertainty.uncertainty.
Errors in medicine are not only a system problem, Errors in medicine are not only a system problem, the physician factor is crucial. Managing uncertainty the physician factor is crucial. Managing uncertainty has its own challenges.has its own challenges.
But: Systems can support physician decision-But: Systems can support physician decision-making in different ways to enhance quality of care.making in different ways to enhance quality of care.
““The practice of medicine is The practice of medicine is an art based on science“an art based on science“
Sir William OslerSir William Osler
Thank you very much for your attention!
Special thanks go to:Lola Adedokun
David BlumenthalAlexander Bock
Larry BrownMichael Gaitanides
Annetine GelijnsSherry GliedJack Rowe
Tom RundallShoshanna Sofaer
Mario Weiss
…and The Commonwealth Fund!