Wednesday, October 3, 2007

Toxic side effect: Valley Baptist and Evidence-Based Medicine

Recently, a group of physicians in the Emergency Department (ED) of Valley Baptist Hospital in Harlingen, Texas, announced they would resign in December, claiming the hospital administration’s focus on metric results could reduce the doctors’ income and compromise patient care. Specifically, they said the hospital’s goal of reducing emergency room wait times and operating-room turnaround time was putting patient care in jeopardy. Hospital administrators said their goal is to maintain high standards of patient care, and that staff and physicians are expected to adopt the new standards.

Meanwhile, at an emergency meeting, 121 of the hospital’s 136 physicians voted to support the ED doctors’ decision to resign, saying the physicians’ departures served as an example of “poor administrative leadership” by hospital leaders. The doctors said they would ask the hospital’s board of directors to investigate the reasons behind the vote and take action. You can read more about the disagreement here.

Luckily, the two groups were able to reach an agreement last week that will allow the physicians to continue practicing at the hospital for at least the next five years. (You can read more about that here.)

The actions of this medical staff’s vote of no confidence for the administrative team could, on the initial blush, be seen as a vote of non-support for evidence-based medicine. However, anyone in health care would be hard-pressed to state that utilizing procedures and processes in the treatment of patients that is not supported by evidence create better and more sustainable health care outcomes.

So in essence, what is the problem here? Rather than coming to the conclusion that evidence-based medicine is wrong, it is best to reflect on the following missteps, which were probably undertaken when the administration’s otherwise acceptable protocols on evidence-based medicine were introduced into Valley Baptist Hospital.
1. The administrative staff did not reflect adequately on the toxic side effects of these changes, i.e., the expected pushback one gets with the introduction of guidelines—and discuss them openly with the medical staff so that all parties were prepared for the physician’s professional pushback. The importance of determining in advance the toxic side effect of any change was discussed in my post, “The Toxic Side Effects of Change.”
2. The distribution of these guidelines in draft form for vetting by the physicians or at least the medical executive committee of the staff appears to have been lacking. This process would have given the physicians an opportunity to present their acceptable exceptions to these guidelines and provided the administrators with an opportunity to determine where flexibility might have been appropriate in their implementation. Ownership of guidelines based on evidence-based medicine is required by all members of the health care team, but especially by nurses and physicians.
3. It appears that the administrative staff might have ignored one of the best ways to develop ownership of what could be considered controversial guidelines: by implementing them in several pilot areas in the organization, after which administration and physicians could together commit to reviewing the findings of the pilots (the lessons learned), and then make any changes necessary and acceptable before the guidelines are instituted hospital-wide.

As I have stated in prior posts, health care is complex, and making appropriate transitional transformational changes in health care is a mammoth undertaking. But because there is wide variation in the performance and outcomes of health care providers in the U.S., as proven by multiple reports over the last several years, including “To Err is Human” from the Institute of Medicine, the development of practice guidelines based on evidence-based medicine is essential. And because it is my belief that most physicians and nurses want to practice the very best that health care has to offer because of the sacred work we are doing to care for patients and their families, they willingly and quickly want to support and implement evidence-based guidelines. Therefore, I believe that the resistance we have seen specifically in this instance (but we recognize occurs in most organizations when change is fostered), is predominately the result of the process of implementation rather than with the evidence-based guidelines themselves.

Hopefully, the several steps outlined above will make this process better and could provide learning both for Valley Baptist and other organizations that are implementing these necessary changes.

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