Should or must? That was the sticking point. After months of hard work, it had come down to this.

In a sense, these words are synonyms. In reality, they are words, and they are worlds apart.

This discourse occurred within a task force I am working with to clinically transform our medical center—that is, making an institutional commitment to quality improvement (QI), patient safety, and clinical efficiency. The effort, in part, is driven by value-based purchasing, public reporting, payment reform, and the like. But mostly it’s being driven by the fundamental premise of doing right by our patients.

We all agreed that we have to change, that it will be hard and even what types of change are needed. The struggle came down to “should” or “must.”

I’ve used several columns imploring hospitalists to lead the quality evolution. I’ve spent less time explaining how to do this. It’s one thing to say, “Hospitalists are perfectly positioned to fundamentally change the quality, safety, and efficiency of hospital care.” It’s another to fundamentally change the quality, safety, and efficiency of hospital care. So, with the disclaimer that my HM group’s efforts to improve quality have only begun to scratch the surface of success, here are some of the lessons I’ve learned.

Start Urgently

Change is very hard for hominids. We favor the devil we know. Therefore, change requires establishing a sense of urgency for the change. Conceptually, QI is enticing—until it gets hard. Then the inevitable changes in workflow start to feel like a lot of work, often without obvious or immediate benefit.

As such, people have to believe there is a problem before they can muster the energy it takes to change. I’d submit to you that the problem with patient safety and quality in healthcare is that most of us don’t think there is a problem.

It takes someone to show us there is a problem before we can change. If you cannot create this sense of urgency for change, you should stop. Don’t continue to try to lead change. You will fail. Guaranteed.

Thus, the most important step in transformation toward quality is convincing people of the need to change. This is hard to do and requires our second step.

Leading The Ship

Leadership. By which I’m not talking about the person in charge, the autocrat, the boss. Leadership is getting people to go somewhere they otherwise wouldn’t have gone. A boss can do this, but most often this is done by the people in the trenches, by front-line people who see a problem and aspire for change, by people like you.

Quality needs leadership; we are its leaders.

The most important step in transformation toward quality is convincing people of the need to change. This is hard to do.

20/20 Vision

A vision is the end game; it’s the finish line, that thing we are all striving for. It’s a big, inspirational, audacious goal that we can all rally behind. It’s things like “zero harm” or “no avoidable errors.”

The vision should not be confused with the plan. Plans are great. But plans that don’t tie back to a vision are destined to fail. Why? Because change is hard, and as soon as a plan (e.g. call PCPs on each discharge, reconcile 24 medications in a demented patient) gets hard, people stop doing it.

Show them, however, how the plan (often something they don’t want to do) ties back to the vision (something they want to do), and people are more likely to follow. I’ll put in the extra effort for medication reconciliation (plan) if I believe there is a problem (sense of urgency) and that this plan helps achieve the vision (no avoidable errors).

Have Patience

Administrators rightly want solutions yesterday. But clinical transformation of this type takes time. We will not unfurl the “Mission Accomplished” banner in three months. This will take years, probably a decade. For two reasons:

This requires culture change, which takes time.

We need bench strength.

A focus on quality cannot be accomplished with five or even 50 people working on this. Rather, it requires 500 to 5,000 people—indeed, the entire organization. It takes time to change the culture, engage the people, and make the mistakes that success requires.

Make It Easier To Do The Right Thing

We have to remove the barriers that limit success. This means not asking high-paid physicians to do chart abstraction, analyze data, and coordinate meetings—support staff should perform these tasks.

We also need institution- and provider-level data. Without valid and timely provider-level data, it is exceptionally difficult to create the needed sense of urgency for change. Show me I’m not meeting my expectations, and I’ll do what it takes to change. Leave me to believe that I’m the best doctor in the world—as we all are, of course—and I have no impetus to improve.

Success requires the infrastructure that makes it harder to do the wrong thing and easier to do the right thing.

Show Me The Money

Quality cannot be an unfunded mandate. Infrastructure needs to be built, support staff hired, and physician time protected to devote to this work.

That being said, I’d submit that if after five years an institution doesn’t see a return on investment (in cost avoidance and increased revenue) of at least 5:1 for every dollar spent, then either you’ve built it wrong or we are all misreading the tea leaves in terms of value-based purchasing. I wouldn’t bet on the latter.

Partner With Your Partners

Medicine is a team sport. True success hinges on a multiprofessional approach. Our success will be directly proportional to the degree to which we engage our clinical-care partners.

This is a less autonomous way of thinking than most of us were taught. We studied alone, took tests alone, saw patients alone. To engage nurses, therapists, pharmacists, and hospital administrators in a dynamic team is outside most of our comfort zones.

Culturing Change

We cannot mend our broken system until we begin to do things differently. Success demands that we work in teams, partner with our hospital administrators, and agree to be measured. We must better communicate with other providers, reduce variability, forgo some autonomy, and shift from physician- to patient-centric care models. This will be hard. This will be uncomfortable. This will require tough decisions.

Failure or Success

Which brings me back to our task force’s definitional divide. The issue was how strongly we push physician involvement in our quality and safety program. Do we encourage all doctors to participate (doctors “should”), or do we require all doctors to participate (doctors “must”)? The task force was divided.

On the one hand, it’s hard to mandate involvement. This would be a huge physician commitment. It would take a lot of training, time, effort, and money. There would be innumerable challenges, perhaps physician turnover.

Was this a battle worth fighting? The difference between “should” and “must” is quite small. They say nearly the same thing. Except they don’t. “Should” says it’s optional; “must” is a mandate. “Should” says it’d be nice if you’d do this; “must” states it’s an institutional priority.

This distinction is not small. It is the difference between indifference and commitment, between our present and our future, between failure and success.

Dr. Glasheen is physician editor of The Hospitalist.

For more tips on getting quality programs started at your hospital, visit www.hospitalmedicine.org/thecenter.

Physician Involvement in Hospital Quality and Safety Programs