Great Hospitals Need Great Doctors

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The last few years have seen major improvements in the quality of medical care in hospitals offering medical tourism services across the world. The impact of accreditation has served to ensure that safe practice has been disseminated and accreditation awarded to facilities that after rigorous inspection have proved that they meet the standards of the accreditation body.


Patients are therefore more easily able to identify facilities that have policies and practices in place that evidence the commitment of the establishment to high quality medical care. The increased use of internet sites to assist patient choice allows potential patients to make more informed choices taking both cost and safety into account.However the facilities and policies of a medical establishment tell only part of the story. Even the best facility is dependent on another key ingredient the doctors and medical staff who work there.


They are the people on whom the reputation of the hospital depends great doctors attract new clients by recommendation. Conversely serious negative publicity can be generated by the exposure of poor medical practice. As patients become better informed so the level of their expectations of care rises.Doctors are in general conscientious practitioners who work incredibly hard to offer the best possible service to their patients.


They are committed to providing high quality care and take pleasure and pride in the outcomes of their work.In many settings they work independently and receive little professional feedback from peers or management. This can make the life of a quality manager with a batch of new hospital policies to disseminate and with the responsibility of informing medical staff using the hospital of the latest agreed safe practices challenging.


I have personally seen examples of hospital managers being reluctant to question known bad practice in case the popular doctor would choose to work elsewhere to avoid changing a lifetimes habits resulting in loss of revenue to the hospital.The measurement of outcomes provides a useful tool to ensure that practices within the hospital are optimal. This is particularly useful in surgical specialties and to monitor indicators such as infection control.


Poor performance on these indicators can ensure that a review of practice highlights areas requiring further investigation training and resultant change in practice. Increasingly patients are asking for outcomes evidence and in the case of surgeons evidence also of the number of procedures performed by particular surgeons before committing to surgery.Whilst most doctors will be excellent ambassadors for the hospital or clinic a particular challenge especially with doctors who are not directly employed by the hospital is to identify those few doctors who are not performing adequately either because of training needs or for personal reasons.


A poorly performing doctor risks not only the health of their patient but also the reputation of the hospital.Doctors are good at helping their patients but may be less good at helping themselves when necessary. They are less likely than their patients to ask for help for their own medical problems especially if they are suffering from what they perceive would be a stigmatizing illness such as mental health difficulties alcohol or drug abuse. Self prescribing or corridor consultations may replace conventional care as the doctor struggles with the concept of taking on the patient role whilst maintaining their own professional practice.


Early identification of these doctors enables adequate confidential support to be offered to ensure that appropriate action is taken to protect both the doctor hospital and crucially the patient from the inevitable long term consequences of poor performance. Setting up a system to identify these individuals requires several key components. Firstly the system must be seen as having some advantage for doctors taking part. It must not be perceived as a performance management tool but as a supportive and confidential process. Doctors must trust that it exists for their benefit as well as for patient care.


It must be evidence based and the assessment not rely solely on the doctors own perception of their performance.An annual review or appraisal can serve the purpose well. Often preparation for the review is seen by doctors as the most helpful part of the process providing an opportunity to think about what has happened over the past year reflecting on how much work has been done and how much has been achieved and to think about what feels important for the coming year.


In the vast majority of cases the review will be an opportunity for the doctor to celebrate all the hard work they have done and to discuss any problems they are experiencing working at the hospital. This in itself acts to boost morale and increase loyalty to the hospital.Maria Bugeja owner of Saint James Hospital Malta was keen to look at developing a system to offer annual reviews to medical staff at the hospital. In 2009 a team of experienced external medical appraisers were invited to conducted appraisals of both medical and management staff. The experience of the hospital was overwhelmingly positive.


Post appraisal feedback sought from staff involved in the process.The second round of reviews in 2010 once again proved to be successful with numerous areas for development of services within the hospital identified allowing the hospital to improve systems and staff morale.In order to conduct a meaningful review it is essential that evidence of both achievements and difficulties is submitted. Evidence that is useful in these reviews includes the doctor describing exactly what their job entails personal audits outcome data significant or critical event discussion and evidence of learning which implies not only attending courses but also how that learning has been put into practice to benefit patient care.See enough patients and all doctors will receive complaints.


Some will be minor and some more concerning. Discussion of the effect of the complaint on subsequent care ensures that lessons are learned. Doctors tend to be perfectionists and a serious complaint can significantly undermine confidence. A review of all complaints received throughout the year may highlight areas which need addressing by the hospital if common themes recur.Health in its widest sense should be addressed ensuring that any problems that may affect patient care are identified and appropriate support offered. Doctors should be strongly encouraged to seek medical help when required and to when necessary have an independent view of their ability to work safely.Poorly performing doctors or doctors in difficulty have often already been identified by staff who may not have an easy way of communicating their concern.


There are many examples of tragedies that could have been averted if concerns had been shared. Numerous multisource feedback tools are available enabling anonymous feedback from colleagues to be included in the annual review. This area needs to be addressed sensitively as it is important that doctors do not feel threatened that this may result in the losing face. In reality the feedback is usually excellent and always helpful. One doctor recently was amazed that her colleagues wished she would sometimes say no. She was exhausted with too much responsibility on her shoulders but felt obliged to take on more and more when asked.


Her colleagues were in fact delighted to be more involved themselves and relieved that she was able to decline further responsibilities.The basis of the review discussion is one of mutual trust and honesty. In order to make this possible it is important that ground rules are established at the beginning of the discussion. These will vary according to the values of the organization but the basis should be of a confidential discussion with the proviso that should any issues come to light which may adversely affect patient care that these will be acted upon accordingly.


An agreed written record of the discussion is kept by the doctor and the hospital and a personal development plan agreed following the discussion. This should address learning and professional development needs with objectives deadlines and plan for each need. Different organizations will have their own view as to how much detail should be included in the record and who can have access to it.As part of the discussion the doctor should be invited to give their feedback on the organization what works well and what could be improved upon. Sometimes similar themes emerge throughout several reviews giving the hospital an opportunity to reflect upon possible improvements.


Often simple changes can make a big difference and make doctors feel they are both valued and listened to.The review can be a time when frustrations and concerns are shared and it is essential that adequate training is offered the reviewer. The choice of person is vital most doctors prefer to have a discussion with another doctor but probably not one with whom they work closely. An independent reviewer model can facilitate more honest and open discussion. It is essential that the reviewer or appraiser has adequate training to prepare them for this role which requires a combination of well developed listening skills empathy and ability to both support and challenge.


Should significant difficulties be identified support mechanisms must be readily available. Health related issues must be handled sensitively but robustly with the involvement of healthcare professionals. Some doctors feel stuck and unable to resolve their work related difficulties or career choices alone. An effective local mentoring scheme can enable doctors to find their own solutions and move on in their career. Mentoring or coaching should be conducted by appropriately trained individuals who are able to facilitate personal and professional growth of the individual.So why is all of this important?


Successful medical tourism provision whether international or domestic requires excellence at many levels. The facility needs to be of high quality and to be seen to practice in safe evidence based way. It requires effective marketing and a reputation for having good outcomes.However most importantly it requires its staff to uphold that reputation. The annual review of doctors serves two important functions. The vast majority of reviews will acknowledge the evidenced hard work done by the doctors listen to concerns and frustrations and agree action plans for the coming year.


The important minority will identify doctors in difficulty and offer support to enable them to have the best chance to return to effective practice before patient care is compromised.Doctors have a duty of care to their patients but also to themselves to ensure that they are performing safely to the best of their ability. As with all quality initiatives the important thing is that ultimately the patient benefits. A safe doctor is more likely to have a satisfied patient.

About the Author

Dr. June Smailes MB ChB DCH DRCOG qualified as a doctor in Sheffield UK in 1981. After working for 25 years in clinical settings in hospital and family medicine including being senior partner of a 4 doctor practice she became interested in the assessment of quality of healthcare. Becoming a lead surveyor and Board Member of Trent Accreditation Scheme in 2006 she had the opportunity to visit medical facilities internationally as well as presenting at meetings on the importance of improving quality in healthcare. Following training in Doctor Appraisal and Mentoring and with 4 years experience in providing these services she offers advice and training to organizations wishing to set up tailored systems to suit their organization. Contact junesmailes@btinternet.com for further information.