Chapter 16: The Office of Medical Affairs: Credentialing, Quality Indicators, and Building a Culture of Improvement and Quality Care

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Chapter 16: The Office of Medical Affairs: Credentialing, Quality Indicators, and Building a Culture of Improvement and Quality Care

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Dr. Rodriguez explains a key function of the Office of Medical Affairs: to credential all individuals at MD Anderson to ensure their competence. She next explains that, since 2009, MD Anderson has been involved in developing performance and quality indicators for professional practice. She explains this history of this focus and the different reactions of clinicians to professional evaluation, given that most evaluation is perceived as adversarial and punitive, rather than part of a culture of self-awareness and self-improvement. She comments on Texas requirements that support a culture of improvement. Dr. Rodriguez then talks about how the Office of Medical Affairs created an infrastructure to shift to quality indicators.

Identifier

RodriguezA_03_20150501_C16

Publication Date

5-1-2015

Publisher

The Historical Resources Center, Research Medical Library, The University of Texas Cancer Center

City

Houston, Texas

Topics Covered

An Institutional Unit; The Administrator; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; MD Anderson and Government; Understanding the Institution; The History of Health Care, Patient Care; On Care; The Life and Dedication of Clinicians and Researchers

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Tacey A. Rosolowski, PhD:

All right. OK, so our counter is moving, and we are recording. And it is 10:23 on the 1st of May, 2015. And I’m Tacey Ann Rosolowski. Today I’m on the 18th floor of Pickens Tower in the Office of Medical Affairs, or actually in the Physician in Chief’s Office.

Alma Rodriguez, MD:

Suite.

Tacey A. Rosolowski, PhD:

Suite, yes, interviewing Dr. Alma Rodriguez. This is our third interview session together. So thanks for making the time.

Alma Rodriguez, MD:

Oh, not at all. My pleasure.  

Tacey A. Rosolowski, PhD:

We started talking last time about—well, we talked about the survivorship program, which I guess is part of the Office of Medical Affairs. But we hadn’t really talked about the office in general. And so I wondered if you could start off that discussion by telling me what’s the mission of Medical Affairs, and what’s your philosophy, what was your philosophy as you took the office as a Vice President.

Alma Rodriguez, MD:

Well, the core, really, the core responsibility of the Office of Medical Affairs is to oversee that the Physicians and Physician Assistants, as well as other licensed independent providers who provide the care for our patients are truly competent individuals; that they indeed have the appropriate—that they’re legitimate, that they have the appropriate credentials that they say they do, and that they have a track record of competence. So part of our job, a very core part of our job is to perform the function of credentialing, what is called “credentialing,” and that is to confirm and verify that individuals who are working at this organization, MD—and who are what are called independent providers, that is, the professionals who are licensed to provide medical care, Physicians, mid-level providers, psychologists, physicists, etc., that they’re all, indeed, well-trained, that they meet the competent standards of the organization. That’s step one. And secondly, added onto that, since 2009, we also established a process of what we call ongoing professional evaluation. And so we had to build the infrastructure, measurement of metrics, decision on metrics across the organization to follow and monitor performance, etc.

Tacey A. Rosolowski, PhD:

Why was that—why did that happen in 2009? What was going on at the time?

Alma Rodriguez, MD:

: Well, the Joint Commission, which is one of the main accrediting bodies for health organizations in the United States, as part of an over—really, it’s a national movement that began even before 2009, even further back. The issues of quality of healthcare were being discussed, that it wasn’t enough to simply provide healthcare, but that we should look at what is the quality of the healthcare we provide. And there are a number of national indicators that apply to general hospitals, cancer care hospitals were somehow exempt from that and still are; some cancer centers are still exempt from that, although that’s changing as well.

Tacey A. Rosolowski, PhD:

Why is that? I mean, I don’t, I hope that’s not too much of a [inaudible].

Alma Rodriguez, MD:

Well, cancer hospitals are not general hospitals.

Tacey A. Rosolowski, PhD:

Oh, OK.

Alma Rodriguez, MD:

We have a very unique and different category of patients, or sub-type of problems with our patients that are not common in the general population. I mean, and general hospitals deliver services that are mostly directed at the more common illnesses; cardiovascular disease, diabetes, infections and other conditions of aging, as well as healthcare for delivery of babies, etc. So we are sort of a bit off the beaten track. And also you must remember that until the 1960s, most patients who had cancer died of the disease, so it was considered a terminal condition anyway. And how do you build quality indicators around terminal conditions, you know, and so on. So for the longest time, now that we are successful, and now that we know that there is a significant probability of survival for many, many patients with cancer, now the question is, are you doing curative treatments, you know, what are the best standards for curative treatments? Are you doing them according to the standards, and so on and so forth. So in any event, they are now—there’s now this movement to apply what are called “quality indicators” to all providers across all professions, regardless of the specialty, and we are not exempt from that. So we monitor, like I said, ongoing professional performance indicators. It’s one of our requirements for credentialing from the Joint Commission. That’s part of our job, as well. That’s one of our tasks. And it sounds very simple, but it’s not. It’s rather complex.

Tacey A. Rosolowski, PhD:

What are some of the complexities that arise in that kind of valuation?

Alma Rodriguez, MD:

Well, where do you get the data? That’s complexity number one. How do you measure these endpoints? Which are the valid endpoints to measure? What are the appropriate endpoints to each specialty? What are appropriate endpoints that apply across the board to everyone? So a very simple measure that applies to everyone across the board is, do your patients complain about you? (laughs) And how often, how many times? That’s one, for example. So in any event, so there’s—another one is, what’s the—for surgery, what’s the mortality of your surgical interventions? How many of your patients die from the surgical interventions? How many of your patients have infections after surgery? How many of your patients—in general, across the board, how many of your patients that you admitted to the hospital that are discharged, how many end up coming back into the hospital within forty-eight hours, meaning probably there was a bad judgment call on their readiness to leave the hospital. So those are—I’m just explaining, you know, the—but it takes a lot of dialog, a lot of discussion, a lot of soul-searching, quite frankly, on our part, as well as the part of administrators, to say what really does matter.

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

What is the—you know, what matters when you give healthcare?

Tacey A. Rosolowski, PhD:

Well, I was going to ask you, because it sounded, with some of the issues that you were raising, that by asking those questions, you’re starting to create kind of a cultural change in an organization that delivers healthcare. And I’m wondering, you know, has there been resistance to that? Have there been philosophical discussions? You know, what’s been the reaction, you know, of different generations of care providers here at MD Anderson, as they have engaged with those questions?

Alma Rodriguez, MD:

Right. Well, it depends, as you said, on the specialty and on the generational boundaries, if you will, of the groups that are engaged. Some sub-specialties have been, by the nature of their specialty, are very familiar and very engaged, and in fact welcoming of indicators. One specialty that, for really decades, has been striving to improve its outcomes is anesthesia. You know, they have to shepherd the patient, if you will, through the whole process of the surgical intervention. They must keep them free of pain, but yet they must keep their vital signs and their vital organs functioning properly and appropriately. They must bring the patient out, hopefully with not too many side effects from the anesthetic. So they’ve been monitoring that for a long time, I mean, literally decades, have had internally-driven quality endpoints that they measure. But for other organizations, for example, medical oncology, it’s very difficult to determine, or it has been difficult to determine what are best measures. One of the national organizations called the American Society of Clinical Oncology recently, over the last ten years, finally started to establish some endpoints of quality through a program they call the Quality Oncology Performance Initiative. And they’ve, again, had their own committees internally to decide what might be indicators and so on, but it’s not a widespread practice. And some institutions have embraced that, others have not. For us, for example, we have not been following those indicators for medical oncologists for the main campus, whereas in the community clinics, our outreach clinics, do follow those indicators. So even within an organization you can have subsets of individuals who embrace the culture, if you will, of self-measurement, versus others resist it. Our surgical colleagues, there’s been a national movement to measure surgical endpoints, and again, initially, very resistant. Our internal culture was very resistant to it. But we had some young people within the organization who had had experience with the national indicators at their own training programs outside of MD Anderson, and they championed it. They said, “Oh, this is good for us.” And now that we’ve had the so-called National Surgical Quality Indicator Program, the NSQIP program, embedded in the organization, now everybody wants to know what their NSQIP indicators are in the surgical world. So it’s interesting. I mean, it does take time. It takes having champions, people who understand the objectives, the goals of such processes, and who are able to speak to them and speak about them in a way that is not threatening, in a way that is supportive of the practitioners, in a way that really empowers the practitioners to look at their own practice. The whole field of quality endpoints is supposed to have underlying it a culture or a philosophy of improvement, not of punishment. Not of punitive measures, or rather self-assessment and self-improvement. Having said that, the tradition in medicine for many generations has been one of, for lack of a better word, you know, of shaming and punishing those that don’t perform up to standards. And so, I mean, it’s also embedded in our culture, the whole litigious environment of malpractice. It’s not about ‘let’s learn from this unfortunate adverse event,’ it’s ‘let’s see how much money we can milk out of the hospital and the doctor’ kind of attitude. So it’s not, for better or worse, a culture in the United States does not support, you know, this whole movement of self-improvement and quality. Having said that, there have been some—in some states, there have been seminal legislature that is helping to support that. And Texas is one of those states. It’s not well-known, but it is one of those states; it has tort reform, it limits amounts of malpractice. For example, it limits—in general, it has moved towards a culture of supporting physicians’ improved practice, rather than just have punitive outcomes. But nonetheless, that still has not left us, I mean, it still exists. You know, the whole negative attitude still exists.

Tacey A. Rosolowski, PhD:

When I was doing your background research, I’m trying to remember, I know I was doing some work with someone’s background, and I read the phrase “appreciative inquiry.” Were you the person who was work—were you working at all with appreciative inquiry, and—I was just curious because that’s obviously very much based on self-improvement—

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

—and self-evaluation moving to self-improvement.

Alma Rodriguez, MD:

Correct. I mean, that essentially the intent of, we hope, of the entire, if you will, culture of medicine, moving forward. It has to shift, really, from this adversarial relationship between society, the environment, the patients and the Physicians. And what is most—what is really tragic and what is very paradoxical is that most patients do not want to have an adversarial relationship with their Physician or with the healthcare institution that provides care for them. And but it always—it’s just the negative few, or the few rotten apples, so to speak, that can spoil the entire barrel.

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

You know, so—

Tacey A. Rosolowski, PhD:

It’s also a mindset, you know?

Alma Rodriguez, MD:

It’s a mindset, yes.

Tacey A. Rosolowski, PhD:

I think there are some people who, just as individuals, you know, don’t have that mindset to say, well, I’m going to take some kind of negative event and then turn it around and learn and move forward from it.

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

They process that information differently.

Alma Rodriguez, MD:

Differently.

Tacey A. Rosolowski, PhD:

Emotionally, in terms of data, I mean, all kinds—

Alma Rodriguez, MD:

Intellectually, and so on.

Tacey A. Rosolowski, PhD:

Yeah. Yeah.

Alma Rodriguez, MD:

Yes, of course.

Tacey A. Rosolowski, PhD:

Yeah, very interesting. Now, I kind of derailed you with that discussion about culture. Were there more things evolving from that initiative that this office has taken on to create those measures, just so we complete that story at the administrative level?

Alma Rodriguez, MD:

Well, so we created—I mean, to do all of that requires, you know, really a large infrastructure; you have to have, as I said, data sources. So we had to look at our data sources. I had to build partnerships with the Office of Performance Improvement, because the measurement engineers are in the Office of Performance Improvement; they don’t report to me. So looking, or building alliances with the right groups of people was important, and then realizing again that there is no one individual that can truly understand the complexity of each of the domains of medical practice. Essentially, within each of the domains of practice, there have to be internal content experts, or experts in what matters to that profession. So we also developed policies and processes and established, implemented, the development of a Quality Officer role within each of the clinical departments, so that those individuals would carry out, then, this function of oversight of specific indicators. Now, some departments again have taken it on very, very seriously, versus others. Some departments have extremely robust processes to share the data internally, discuss it amongst themselves if there are adverse events, that there’s a methodology for, if you will, [inaudible], doing a tracer for the events, what happened here, where did things go wrong, what needs to be fixed so it doesn’t happen again. And usually, those have been the procedural departments, if you will, like [Department of] Pulmonary Medicine, [Department of] Gastroenterology, because they have to understand the methodology—you know, what occurred during the procedural care delivery that maybe can be done better. Others have taken a more lackadaisical attitude, and have said oh, well, that’s just a Joint Commission requirement, it’s not about us. You know? (laughs) So we have a very divergent, at this point in time still quite divergent group of quality officers, some of whom are extremely and highly engaged and knowledgeable about what it means to have self-assessment and quality oversight and others that are very peripheral to the process. (pager is heard)

Tacey A. Rosolowski, PhD:

Should I pause for a moment?

Alma Rodriguez, MD:

Let me just see if this is a critical page or not. Message, oh—they’re just telling me I’m covering someone. OK. Somebody else’s pager is being dropped onto my pager. So anyway, so that was another initiative, so getting the department chairs engaged in appointing such an individual. Some department chairs have said this is a waste of time, others have said oh my gosh, it’s about time we did this. So again—

Tacey A. Rosolowski, PhD:

Huge range of reactions.

Alma Rodriguez, MD:

Yes. A whole range of reactions. But slowly, slowly I’m seeing a shift towards a—the number of individuals who say this is important is becoming larger and larger. So that’s encouraging. And it’s very timely, because on the national scale, like I said, you know, starting this year, we will be required to report what are called the Physician Quality Report Indicators, PWRIs. And it will be publicly reported in a federal domain on one of the federal Websites, anybody can go and look at their Physician’s quality scores.

Tacey A. Rosolowski, PhD:

Wow. Wow. Wow, I’m sure that’s making some people mad and leaving them shaking in their boots—

Alma Rodriguez, MD:

Yes.

Tacey A. Rosolowski, PhD:

—or saying OK, huh, good shift—

Alma Rodriguez, MD:

A lot of them are annoyed. It’s going to be a very big challenge. So they’re starting off, of course, first of all, with organizations that have large numbers of physicians in their organization, because they understand that those are the organizations that are likely going to have the measures or the numbers or the data sources to measure. But it’s gradually moving to every single physician in the United States, even if they have a single office, single physician, single office practice. They’re going to have to figure out how they’re going to track their own measures of practice quality—

Tacey A. Rosolowski, PhD:

Interesting.

Alma Rodriguez, MD:

—to report.

Tacey A. Rosolowski, PhD:

Wow.

Alma Rodriguez, MD:

So, more to come.

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

It’s a shift in the national healthcare scene, as well as a change in the internal environments of all organizations that deliver healthcare.

Tacey A. Rosolowski, PhD:

Very interesting story.

Alma Rodriguez, MD:

So that’s, you know, that’s a core function of our organization, do we have the right people delivering the right care? And are they doing it well?

Tacey A. Rosolowski, PhD:

Yeah.

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Chapter 16: The Office of Medical Affairs: Credentialing, Quality Indicators, and Building a Culture of Improvement and Quality Care

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