| 1. |
for question above i am ceo and also a practicing MD |
| 2. |
Resistence to change |
| 3. |
A lot of lip service to quality but not much movement over the years until Medicare began pay for performance. This helped push idea of dedicating nurse/CM to ensuring Quality Indicators have been meet. Computerization has been slow and painful. Vendors promises are being slowly met at great cost. Nursing model changing to "Patien Centered" is good in theory but now we are paying nurses to change bed sheets! That's crazy use of resources. But here in California, ratios are supposed to improve patient care. I don't see it happening. |
| 4. |
Organizational structure has been changed to provide direct input to the CEO. This structure is not friendly form my position as department chair and practicing physician. There is a perception of lack of respect. |
| 5. |
Medical Director |
| 6. |
There's not enough time and not enough money to do all that we would like to do. |
| 7. |
Our Emergency Medical Services System is broken beyond repair. The EMS in our area is third world. |
| 8. |
SMALL GROUP OF MEDICAL STAFF WHO ARE VOCAL, HIGH VOLUME/CRITICAL SERVICE PROVIDERS WHO ARE RESISTENT TO CHANGING CULTURE |
| 9. |
Money, money, money. Need more resources in staffing beds (nurses), need more beds - inadequate number of ICU and telemetry beds vis a vis ED volume and admission rate. Hospitalist program needs more MDs. |
| 10. |
A primary strategic area for our hospital is quality. Emphasis has been totally on the hospital, nothing in ambulatory care. Focus on staff/nursing changes rather than dealing with physicians. |
| 11. |
mostly communication and inertia. Physicians are taught to think of only one patient at a time, and are poor at communication skills within the organization |
| 12. |
Successfully and respectfully communicating that many errors are due to wrong diagnosis and wrong treatment. |
| 13. |
In a large community, teriary care facility, with a medical staff that is predominantly private practice, the greatest obstacle is getting buy in and finding ways to align the incentives for the physicians with those of the hospital. Creating a win-win scenario is not always easy. |
| 14. |
Costs takes priority over patient safety. |
| 15. |
Administration pay little heed to workload benchmarks |
| 16. |
Resources,patient compliance |
| 17. |
The major obstacle is the mind-set of the Board of directors and the mnagement team. Next step is Setting a culture that enhances the provision of quality care in a safe environment. This should be followed by rewards and disincentives. The major obstacles we are facing is in the board's awareness and commitment to these requirements. |
| 18. |
The payment structure is a huge obstacle, both for hospitals and physicians. |
| 19. |
There is need for educating physician executives about leveraging the strengths that already exist in their organization and approach issues using systemic viewpoint. Physician executives also need to be aware they are fully responsible for the culture and stop blaming others (if they are currently doing so) |
| 20. |
NEED MORE PROMOTION OF EVIDENCE BASED MEDICINE AND CLINICAL OUTCOME MEASURES. |
| 21. |
Every bit helps..... |
| 22. |
Insurance companies. |
| 23. |
Physician compliance and belief that documentation is important. |
| 24. |
Nursing, in spite of going thru various processes which stress teamwork and communication frequently act independently. Outcome measurement in terms of clinical or safety outcome is difficult to get. |
| 25. |
It's seen as the VPMA and quality dept's 'job', as well as nursing/case management, rather than a culture from the board down. Limited resources are deployed for data gathering. |
| 26. |
Hospital organization is not supportive, in many cases. Most hospitals need to re-organize around safety and quality. Usually, these programs are imposed without building them into the organization, and they remain peripheral to hospital functioning. |
| 27. |
time to evaluate and change while trying to maintain productivity |
| 28. |
Time and human resources to work problems to root cause and solve them. An inadequate use of the help chain up to administration |
| 29. |
Quality/safety initiatives are discussed constantly, and we are all expected to increase the amount of work we do to meet those objectives. No additional human resources are allocated, however - in fact the administrative workforce is being reduced through attrition. |
| 30. |
Investments in Safety and Quality are much like investments in stocks: we must have a focused long term horizon and not look for the quick gain. If we do, we will be certain not to achieve our goals. |
| 31. |
Simply...overwhelming ! |
| 32. |
Cultural inertia to continue the same way. Obstacles to change. |
| 33. |
The reimbursement systems incentivise either over-utilization or under-utilization rather than quality outcomes. Pay-for-performance and/or clinical integration may help us address these issues. |
| 34. |
We are predominantly occupied delivering service. Change management is a big burden. There is not a strong financial incentive to make system changes, and there certainly no relief from service demands to create time or capacity to make the change. We are a pediatrics group, so there isn't even the medicare regime to prompt change. |
| 35. |
Lack of cash in a not-for-profit organization |
| 36. |
I recently resigned as Chief of Surgery, because of family reasons. I am still President of a 8 neurosurgeon practice and remain very active in the medical staff leadership. Next year I maay return, but I had multiple deaths in my family and 7am meetings are not as impportants as spending another hour in the mmorning with my children. |
| 37. |
Unreimbursed and under-reimbursed care and the loss of profitable specialty care to specialist hospitals/ambulatory centers reduces funds available for quality initiatives. Obtaining medical staff consensus is very time intensive and often delays implementation of hospital wide or system wide quality intiatives. |
| 38. |
Physician Engagement FOllow through Resources (especially IT) to facilitate measurement and feedback of results |
| 39. |
$$$$$$$ |
| 40. |
The survey seems very much aimed at the provider side of the healthcare industry. As a regional CMO for a national healthplan, the insurer side of the industry is very much involved with quality improvement in healthcare also. A cooperative effort from all aspects of the healthcare industry is a must for quality improvement to succeed. |
| 41. |
Money, time, focus, resources |
| 42. |
Largely the barrier is data collection--very expensive. 3rd party payers are now demanding pre-authorization of expensive imaging which will cost us a great deal in resources that might otherwise be used in QA. |
| 43. |
overcoming resistance to standardization |
| 44. |
Cost is a factor, but not an obstacle in our organization. We recently converted all IV pumps to the latest "Smart Pumps", a costly but good thing to do, to reduce risk and error. Revenue from third party payors is a bit of a dilemma: We get more and more "mandates" to achieve quality and safety, but then get pressures from the payors to accept less than cost on the revenue side. |
| 45. |
Medical insurance reimbursement problems. Too much time is spent/wasted jumping through hoops to get paid by insurers. |
| 46. |
I am VP Physician Services and support the CMO/Senior VPMA. I share my stuggles and sense of frustration above. It has been an awsome privilege to have been a practicing surgeon for many years and now, though less pleasing, a part of the Senior Leadership Team. |
| 47. |
to many entities choose different measures and then all want the Hospital sdto respond to everyone. |
| 48. |
We have effective and efficient quality and safety measures within our own hospital physician network and hospital based physicians, with very good buy in and participation from the physicians. Our problem is with the independent medical staff who seem to think they know everything and the hospital exists to improve their efficiency, and further that quality is defined by their getting whatever they want and not by any meaasurements. They fight us just about every step of the way. |
| 49. |
too often, easily measured parameters are substitutes for 'quality' - low A1C doesn't always translate to lower morbidity or mortality, but has become the definition of quality DM care. It's early in the process of defining quality and how to measure and track it and there are going to be some bad starts til there is better acceptance of what consistutes appropriate definitions and measures. |
| 50. |
Many health plans talk about programs (P4P)as if they measure and reward quality but the programs are really about cost savings. Because each health plan wants to differentiate itself from the next, no two of the programs are alike and a "high quality" physician at one plan is "low quality" at another. Often these measures come only from claims data. This leads the physician to disregard all of these programs as being unreliable and incompetant. This is one of the reasons I regard P4P as just another passing fad. It sounds good in concept but the reality is that no one will commit the resources outside of hospital systems. |
| 51. |
Safety and quality is on the radar screen, but decisions are financially driven |
| 52. |
Time and resources to develop a true baseline. |
| 53. |
The healthcare system(s) are still too fragmented from the perspective of aligning quality outcomes with an incentivized reimbursement model. Pay for performance programs are early in the process of changing the model but consistent standards and methods are not mature enough to allow full adoption. Consumers also need to be more engaged to support transparency along with P4P and a continuous non-punitive learning process for evidence based medical practice. |
| 54. |
As long as the members of Congress are covered by the FEHBP, and as long as they don't have to experience health care in their own jurisdiction, but can get "excellent" care at DC, there will never be adequate appreciation or funding for quality and safety. |
| 55. |
- The culture, mainly safety culture needs more and more efforts to build accureately. - Patient trust on Healthcare system |
| 56. |
There are many campaigns - and digesting the numerous campaign titles makes it seem like we are doing more than we are to front line workers. We are addressing this by fitting the campaigns into a standing quality/safety structure and trying to work the pieces of the work into the front line clinical work flow so that it is a part of what we do instead of another thing to do on top of what we do |
| 57. |
lack of communication between interested parties at all levels iew no stakeholder buyin our hospital is not at all unique in this regard |
| 58. |
Physician indifference-to concerned about reimbursement, overhead and liability costs |
| 59. |
The classic QI project approach largely produces "science fair" experiment results that don't take hold in the overall organization. Organization wide workflow change management to decrease defects, improve productivity and engage the people that do the work is needed to break out of our small scale mentality. |
| 60. |
P4P should focus on also on efficiency of care in order to incentivize hospitals to additionally solve flow and operations problems. Show me a hospital that has 100% antibiotics selection for ICU patients and I might be able to feel confident it is a higher quality insitution for pneumonia patients; show me a hospital that triages all patients within 5 minutes and has *90% of admissions arive at their bed 30 minutes after the admission decision is made and I will be almost certain that qaulity is improved for all patients. Hospitals need incentives to be placed to focus solving operational issues. If the amount of hospital resources that are devoted to core measures were focused on hospital operations, I am confident quality would be impacted. |
| 61. |
At times it is difficult to maximize physician "buy-in" when the hospital/medical staff relationship has changed so dramatically over the last 15-20 years. Hospitalist services now make medical staff interaction unnecessary, e.g. the "empty Doctors' Lounge" syndrome. There may be little to no physician initiatives or willingness to participate in hospital functions. |
| 62. |
Resources - time and energy |
| 63. |
Rewarding hospital managers with bonus money for provinding care with lowest cost (primarily staff)...not necessarily of the best quality nor safest. Now that we have combined our anbulatory outpatient staff with our inpatiet staff, most of the staff feel they go home having NOT done a good job, and not feeling satisfied with what they have done in any particular day .. the old PACU staff feel like they do not do a good job with the ambulatory patients, and the ambulatory staff is absolutely uncomfortabvle with the ICU/intubated type patient. The PACU staff also feel that they are having less and less experience with the intubated/critical care patient, so feel like they do not do a good job with ANY patient, ambulatory or not. |
| 64. |
Quality by following processes developed from population samples are not always applicable to individual patients. Process quality needs to be accompanied by measurement of outcomes for a comprehensive picture of quality -- in other words, quality processes are necessary, but not sufficient, without outcome measurements |
| 65. |
Pay for Performance has provided incentives that have aligned medical group quality programs with payements have been instrumental in our efforts to improve quality outcomes. |
| 66. |
Inherent dangers in implementation of EMR- the "assumption" that EMR is safer simply because of it's presence is false. |
| 67. |
Providers too busy and not taking the problem seriously. They don't see it from the patinet's point of view. |
| 68. |
Time to spend educating patients and their families in a high through put environment. |
| 69. |
Overcoming inertia that stalls change, inertia especially on the part of physicians who refuse to climb out of their rut. |
| 70. |
1) setting up several initiatives that make it hard to not have conflict over what is the first priority 2) not having specific measures of quality be reported back to the provider - ie - RN or MD and have them accountable for performance |
| 71. |
Changing the status quo of Physician and Organizational behavior. |
| 72. |
The time frames for ROI are generally too short, usually one year. |
| 73. |
There are lots of "right" answers to lots of clinical questions, and the patient has a huge vote in what actually happens, so it is difficult to design a "standard" program and then measure compliance with it. |
| 74. |
A big obstacle is INERTIA. It is important to start somewhere, learn, and get some momentum to carry you into newer areas. With the growth of knowledge will come impetus to continue, and the results will follow. |
| 75. |
Quality cannot be relegated to the Quality department or nursing staff. There must be a 100% commitment from the "C" team, "A" team and engaging board of directors in the effort. We are embarking on the quality journey at my organization and it is slow going. Everyone talks about better quality but everyone thinks they are doing just fine. There is a lack of understanding about just how far we need to go to reduce variability and get everyone involved in patient safety. |
| 76. |
Our hospital is a for-profit institution and any change is seen merely as a way to increase profits. Anything suggested by the medical staff is scrutunized for pennies and consequently, not implemented or even tried in anything resembling a timely manner. |
| 77. |
In general, lack of leadership at the organizational levvel absolutely kills the efforts to improve the system-wide efficiencies and safety initiatives stemming from the clinical staff. |
| 78. |
Physicians are reluctant to change. They fail to see improving care benefits all. |
| 79. |
Lack of physician leadership to implement quality initiatives. Most of the responsibility lies with private practice docs who are NOT paid for their QI/peer review work. In todays environment they're more worried about paying their bills and making a living than improving quality. My fear that is that the government will mandatte things but not provide any resources to cover the cost. To simply take away money from docs only to give it back to them if they meet "quality" metrics won't work. I think docs will throw their hands up and sa it isn't worth the extra time/effort to get the extra money that only gets them back to wherre they were last year. |
| 80. |
inlfexiblity of the Joint Commission in some areas that then detract from physician buy-in in other more critical areas |
| 81. |
There are no incentives to improve quality or safety. |
| 82. |
Production pressures result routinely in hurried work with inadequate attention to each individual |
| 83. |
Greatest obstacle is not having the decision making financial relationship between the patient and the physician (not the insurance company). This, along with caps on non-economic malpractice judgements, would allow market forces to come into play, and would significantly reduce the overall cost of health care, with a likely increase in overall quality. |
| 84. |
Hearts are in the right place. Insufficient funds slow down implementation |
| 85. |
The organization has too many improvements on the table... |
| 86. |
Physicians |
| 87. |
physician engagement; coding issues |
| 88. |
The biggest problem with "Quality" in medicine is the definition. What is "Quality" as it pertains to each specialty and how do you measure it. Certainly claims data by Insurance Companies is not the answer. Mutually agreed upon, easily measurable statistics for each specialty is what needs to be developed nationally. |
| 89. |
The physician based initiative such as Practice guidelines, have been hardest to institute. Because of hospital corporation based initiatives there is a fairly robust system in place with a full time QA officer (an RN) responsible to Med Exec and the Board for reporting the results of QA activities. This helps but the concentration is on patient complaints, corporate initiatives (CMS data etc.)more than community disease issues such as renal failure and diabetes. |
| 90. |
BOTTOM LINE IS, REIMBURSEMENT IS CUT TO THE BONE. THE COST OF DOING BUSINESS IS EVER INCREASING. GETTING INSURANCE TO PAY IS PAINFUL AND EXPENSIVE. THE BURDEN OF UNINSURED FALLS ON THE PHYSICIAN AND THE ORGANIZATION. IMPLEMENTING QUALITY, WHEN SOCIETY WANTS MEDICINE AT BARGAIN-BASEMENT PRICES, IS DIFFICULT, B/C CANNOT BREAK EVEN WITHOUT HIGH PATIENT FLOW. |
| 91. |
We don't manage health, but cost - and THAT not very well. |
| 92. |
No one with any actual athourity over the medical staff--NOT an employement model by and large. Even for contracted physicians (Rads, ED, Anesthesia, Hosptialists) Sr. Admin won't have the hard discussions. "Work on what else you can accomplish" Abstraction "maze" with constant changes very frustrating in pay for reporting. |
| 93. |
The need to make staff and patient safety a priority over cost. |
| 94. |
Our main difficulty is that there are a limited number of people at this organization who are involved in quality improvement initiatives. It is difficult to maintain focus and momentum with these projects. Real change occurs very slowly. |
| 95. |
Conflict between budget new initiatives physician complacency -- increased work decreased reimbursment makes them much less likely to participate in planning safety initaives |
| 96. |
it's hard to get people to do what you tell them to do. |
| 97. |
initiating a change in medical culture |
| 98. |
As the CMO I oversee an Office of the State Operated Service Medical Director and chair a Statewide Medical Executive Committee (SMEC) made up of three network medical directors, two hospital clinical directors, two psychology services directors, a nurse executive, a clinical pharmacy director and a liaison to the university. I report directly to the CEO and the SMEC reports directly to the Executive Team. This strategy has allowed quality of care and patient safety to be integrated into all strategic initiatives and transformational efforts. |
| 99. |
none |
| 100. |
cost seems to be driver for resource allocation. limited commitment in terms of infrastructure to provide for quality improvement. also, limited desire for self-evaluation. |
| 101. |
Quality initiatives usually focus on underuse issues, safety on misuse and overuse is often avoided because it will decrease revenue for providers but is a major focus for payers, which makes it evil to providers. |
| 102. |
Physician training, independence, silo mentality, culture. Leadership failings. Unwillingness to set the expectations clearly. Reimbursement methods. |
| 103. |
My title is Director, Quality Performance for a children's hospital within an adult hospital. The organizational structure is such that most of the quality inititatives go through Nursing. I am often "left out" of quality discussions. I have been able to have an impact; however, it is difficult and very slow. We are not an academic hospital. Therefore, quality improvement initiatives do not happen by mandate since most of the care is provided by independent, private practitioners. It is difficult to communicate with the majority of pediatricians, for example, since they do not regularly attend meetings where quality issues are discussed and solutions presented. |
| 104. |
Lack of interest and lack of adequate funding. Indifference and/or sense of hopelessness on the part of staff, including physicians. |
| 105. |
Poorly thought out, and not adequately reviewed by clinicians, policies on safety mandated by national organizations (JCAHO pain, unsafe abbreviations, pharmacy review, IS Security to name a few) are forced on practicing clinicians and generate negative feelings becuase of lack of clinical perspective and relevance. Some help, some are neutral, and some clearly hinder ability to provide care. The natural response from the clinician is resistance because some safety initiatives are helpful and some make care less safe. |
| 106. |
Cost is the big one. Secondly, trying to standardize an industry that is wildly variant from patient to patient is difficult if not impossible. Thirdly, convincing physicians and others of the validity of current medical knowledge is a difficult chore. For instance, what we knew to be "truth" in, say, 1996, ends up being entirely wrong in light of new evidence in 2007. It is difficult to convince physicians that we have the "truth" now . . .they know it will change with time. Therefore, standardization with the accompanying cost containment and increase in quality is nearly impossible to attain. |
| 107. |
change in culture and status quo |
| 108. |
Too many "indicators" such as the CMS Core Measures without physician committment. The perception is that most of these are "external", interfere with autonomy, and are compliance mandates rather than truly reflective of longer-term improved patient outcomes. |
| 109. |
I was VP for several operational units. NOne of the titles above fits. In my areas the primary obstacle was getting people - physicians, nurses, other staff - to believe they could make the change. And, to believe that they could provide the best care possible. Once they believed that, and that there was room to improve, there was no stopping them. |
| 110. |
Hospital fear of losing business from physicians, when it comes down to it. |
| 111. |
In the hospital setting, staffing by union employees who are not motivated makes the flow of work significantly worse, slower, ineffective and extends hospital stays and pt work-ups. |
| 112. |
I see the largest problem now as lack of information, accurate data, and problems with communication. At my organization I feel we have turned the corner on attitudes and the old way of thinking. Physicians and staff want info. on how to do better and sometimes have a hard time finding it. |
| 113. |
Competing initiatives and malalignment now cause the usual impedance. Looking at the current mileu, it has achieve the deadly sin of tampering. As example, the failure of the CMS quality indicators to be established with anything but a point prevalence consistency leads to rework and a non-continuous outcome stream. It has developed all the hallmarks characteristic of the Hawthorne Effect - and in some instances has resulted in degredation of care as individual institutions seek to meet the "quality indicators" in the public forums. These types of activities, particularly P4P corupt; the tail now wags the dog. |
| 114. |
FINANCES AND TRAINING AND TIME AND OCC, DOCTOR BUY-IN |
| 115. |
There are way too many patient advocy enities, many for profit. Hospitals are responing to illogical input and uncoooberated data. This is used for competition more often than true qualtiy improvemnt. Health Grades is a prime example. Grades for sale. |
| 116. |
Failure to understand the financial implications of poor safety practices is the major stumbling block. |
| 117. |
We have to care before we can improve. I don't see a lot of caring. |
| 118. |
More deeply engrained and unresponsive constituencies than anticipated with senior leadership and the board not buying the impacts of quality improvement at all.Too many self-interested parties and still too much reliance on surrogate measures rather than true outcomes. |
| 119. |
Physician behavior and full engagement. |
| 120. |
Some big items are very costly: CPOE, EMR Some are complex and difficult to implement because of need for program and system development. Would be eaier by adding layers of bureaucracy and staff, but that adds a new cost. Creating attention to one safety initiative often drains attention from other initiatives. |
| 121. |
Biggest obstacle is practitioner denial of quality issues and failure to engage bed-side caregivers in QI processes. |
| 122. |
1. inability of physicians, especially surgeons to be a part of the team in implementing processes for safety/quality 2. The rigidity and,at times, stupidity of JCHO and federal regs. Mandates backfire frequently - sometimes in such simple ways as taking time away from direct patient care and the enormous cost of documenting compliance |
| 123. |
Given a clearinghouse for examples, organizations can adapt to their needs. There is too much money in consulting, and too many solutions are kept secret for financial reasons. If quality saves lives, it should be studied and published like any other life-saving intervention. If it doesn't, it should be rejected. |
| 124. |
Most physicians and health care administrators have the tendency to maintain the status quo and require a persistent effort to make positive change the new status quo. |
| 125. |
1- Lack of understanding by senior management. 2- Focus from the Board of Directors on cost concerns, with an almost blind eye to quality concerns. |
| 126. |
High visibility issue with low true priority yielding attempts at window dressing rather than real change. |
| 127. |
time and money, not a lack of desire |
| 128. |
I think administration worries too much about cost and it would actually improve the bottom if patients received better care |
| 129. |
Difficult to achieve goals because of financial problems. There is an interest on the part of senior administrators but there are so many competing needs that get in the way |
| 130. |
Resource allocation to Patient safety and quality is a challange and the hospitals of the future need to address this issue ASAP. |
| 131. |
In lean economic times spending the money to force quality and safety into the hospital is really difficult. It is expensive to put into place all the processes and track them properly to ensure quality and safety. However, not doing it is foolish. Quality and safety are essential obligations for our patients. |
| 132. |
Poor reimbursements from payors effects the ability to staff for highest quality. |
| 133. |
I find that in a large health system, which we are in, that there is so much focus on dollars, that the local hospitals in the system are fearful of being proactive and creating new processes and programs, because of the fear of having to shut it down. |
| 134. |
It's such a complex area, there is so much to do and the whole thing is still really in its infancy. It's been difficult to communicat what patient safety to all levels of the hospital and at times to convince them that trying to change things doesn't mean they're doing a bad job. |
| 135. |
Too often the extreme emphasis on applying "EBM" denies the role of art in medicine, fails to distinguish healing from curing, and distances the physician from the bedside. There is a need for outcome criteria rather than process criteria to better gauge practice. Also, what passes for EBM today may (will) be outdated tomorrow. The guideline P4P gestapo can actually stifle creativity, and eny situations where the application of EBM is not in the patients' best interest. |
| 136. |
Communication hand-offs are critical and need further emphasis. |
| 137. |
1. resistance to change 2. the wish for perfect data before making a change 3. systems to maximize efficiency (EMR) |
| 138. |
costs control medicine now. This restricts access to hospital care, medications, compliance, etc. |
| 139. |
One of my biggest challenges lies in trying to cross the chasm between leadership decisions and implementation of those decisions in the trenches. Solving the communication/marketing/implementation process will be key to overcoming this barrier. |
| 140. |
Time pressures to provide patient care, make it difficult for team members to communicate, or even for doctors to talk to each other. |
| 141. |
Your survey seems to make an assumption that the person completing it is at an organization that delivers care. I am at a health plan 100% and do not provide direct patient care, but I am involved in QI heavily. |
| 142. |
A new computer reported to improve quality and safty has made improvements difficult if not impossible - safety issues are daily battle - time spent with computer has taken away time with patients. Very dangerous! |
| 143. |
Major obstacle is aligning resources to have a robust quality/safety improvement infrastructure (staff and IT tools)to address and support the efforts. |
| 144. |
lACK OF VISION AND ABILITY TO DEVELOP EFFECTIVE md RELATIONS TO MAKE THE TOUGHDECISIONS |
| 145. |
Ours is a culture that had very little accountability for physicians. We are currently seeing changes in that but "requiring" vs docs to do anything is still an obstacle. |
| 146. |
Society does not allocate sufficient payment to a hospital in an area serving the poor to allow hospital to implement needed improvements - this is a disgrace to the US Healthcare system |
| 147. |
no comment |
| 148. |
There's a lot of scurrying around to fix things for which there is little to no data. When there IS data--for instance, wearing masks in the OR has NO effect on patient or practitioner health--they are resistant to change. |
| 149. |
Many physicians in our group do not like to be burdened by what they consider additional or unuseful paperwork to followup quality issues. A common statement I hear is .."I didn't go to medical school to be a secretary". Getting buy-in is one of my hardest duties. |
| 150. |
$$$$$$ |
| 151. |
Physicians that do not want to follow the guidelines that we set forth. |
| 152. |
Time constraints on physicians. Physician burnout, cynicism, fatigue, and reluctance to embrace change. Declining reimbursement for physician work. |
| 153. |
administration is slow to implement measures and physician buy-in is poor. |
| 154. |
The approval roadblocks of the Workers Compensation Insurance Companies that delay referral of patients for appropriate studies and consultation. |
| 155. |
There is a major conflict in most struggling, dysfunctional organizations between what I call the cost/quality equation. They simply can't financially afford the cost of promoting quality as it should be promoted, and they don/t yet understand that in the long run they can't afford not to allow time and resources for quality projects with ACPE trained physician champions at the helm. |
| 156. |
Getting the medical staff to agree!! |
| 157. |
Insurance companies interfering and at the same time. reimbursing less and less |
| 158. |
Overuse of testing is rampant with prevention of liability the main cause. Lack of peer oversight and ability to monitor performance with poor availability of data to track quality. |
| 159. |
physicians are struggling to maintain their income with declining reimbursements. This leads to a focus towards their own practice just to keep up with the continued changes. There appears to be a general apathy towards the Hospital patient care issues unless it specifically has an impact on the physician's practice. |
| 160. |
Lack of uniform EMR Overburdened average physician Time constraints |
| 161. |
Too many different organizations with different agendas, priorities regarding safety and quality thus diluting organizations' ability to address all of them effectively. (e.g., CMS, JCAHO, NCQA, national and regional payers, etc.) |
| 162. |
difficult to direct care for qulity when CMO has no authority in any consequencies tied with action of other staff wheather it be a reward or a conseuence |
| 163. |
Resource of time and attention, first to ingrain a philosophy and methodology in the organization, and then to do the improvement projects. |
| 164. |
mainly with physicians who are not employees and have no vested interest. |
| 165. |
Financial constraints, human resource constraints, Law and regulatory impediments |
| 166. |
The productivity model, misaligned reimbursement, lack of collaboration, apathy or ignorance of the need for re-engineering healthcare, etc. all continue to perpetuate the inertia preventing advancements in quality and patient safety. |
| 167. |
Continuously frustrating.... Most frustrating - physician non-cooperation |
| 168. |
safety still not on the same level as cost and financials |
| 169. |
Costs of computerization and education are biggest obstacles. |
| 170. |
none |
| 171. |
There is a general inability on the part of senior management to relate to and understand the importance of medical quality in some organizations. Methods for connecting these activities to real value in the business world are not well developed. |
| 172. |
A little extra financial reward goes a long way |
| 173. |
1. Resources 2. Failure to prioritize 3. maintaining and improving |
| 174. |
Defining quality measures is still in it's infancy. Further, capturing the data tomonitor quality represents currently a major barrier. We are transition to a full EHR implementation that should help. |
| 175. |
Continue to struggle with the concept of medicine as a team "sport" and not "golf". Physicians continue to hold on to their autonomy (wich they really dont have anyway) and nursing continues to want "control" over "their" patient. We have some areas that heve shown that if an evidence based team approach is used you can erradicate most preventable deaths and injuries |
| 176. |
occassionally hoapitals let the "bottom line" compremise safety. |
| 177. |
I beleive that P4P is a poor surogate for quality initiatives. It only addresses areas that can be easily measured. It does not require groups to use the quality improvement process in their every day practices. |
| 178. |
Hospitals are still chasing revenue and are not serious about improving quality and efficiency |
| 179. |
The availbility of reliable data is an obstacle. Data collection and analysis needs to ongoing. Without data we cannot identify problems, cannot compare ourself to our peers, and hvae no baseline against which to monitor progress. |
| 180. |
NA |
| 181. |
Need a more formalized process with oversight from highr=er administration |
| 182. |
Reluctance of physicians to accept transparency in reporting. |
| 183. |
Our Group & the Hospitals we serve, are doing an excellent job for the most part in addressing safety & quality. |
| 184. |
It's ROI is high but it requires major financial investments |
| 185. |
Time, time, time. We have recveived the CMS pay for performance financial "reward" three years in a row at a cost in manpower several times over the award due to documentation/administrative requirements. At all levels every quality initiative requires resources that are not reimbursed and go far beyond the efficiencies gained thereby taking more and more administrative time for clinicians and nurses leaving less and less time for face to face patient care. |
| 186. |
Silo's persist and they are carefully protected. No one really wants to develope a safer system. People continue to protect their turf. Insurance companies are squeezing the physician and hospitals to the point of collapse. |
| 187. |
Change from the status quo. |
| 188. |
1. Our government's refusal to change the tort and liability system. 2. Our government's refusal to enforce a law whereby a plaintiff is automatically made to pay a fixed sum like $50,000 or 5% of the claimed amount, whichever is higher, to each defendant whenever the plaintiff loses the case, for the pain and suffering that the defendant had undergone because of the wrongful suit. When the plaintiff loses a case, that suit should be termed and deemed as a wrongful suit. |
| 189. |
The greatest obstacle is time. Decline in reimbursement to hospitals and physicians requires everyone to work quickly and occasionally cut corners. |
| 190. |
The main obstacle for us is the cost of implementing quality systems. |
| 191. |
See prior examples provided and my ranking of the questions posed. |
| 192. |
Happy that our organization(5 hospitals) has chosen to pursue these initiatives and put administration fully in support. |
| 193. |
Change is very difficult especially with physicians who are not trained in systems management. They don't understand that patients are wigets and should all be treated the same for the same diagnosis. |
| 194. |
showing ROI of quality and PI. |
| 195. |
The major obstructions to safety and quality in health care are physician perceptions of their Protection, Entitlement, and Autonomy (PEA). Like PEA of ACLS, physician PEA produces lip service to safety and quality without generating actual output. |
| 196. |
Even though we have some financial incentives for quality metrics - those are limited to the primary care physicians. |
| 197. |
Lack of physician awareness that this is a serious problem. I believe that forced public reporting by institutions will improve some of that. It is unfortunate that this is not more seriously embraced by physicians as it is a serious issue that is largely systemic and will require a shift in physician attitude and, in my multispecialty physician organization, an increase in expenditures to improve the situation. |
| 198. |
There is a very reactionary attitude among the medical staff to standardization of their individual practices (autonomy is a frequently mentioned word). In this for profit hospital, the CFO has tremendous authority and focuses on a weekly bottom line. Not healthy for long-term projects with no clear immediate financial return. |
| 199. |
none |
| 200. |
The lack of information systems that provide actionable information to pracititoners at the point of care. |
| 201. |
nursing service focused on doctor safety to the detriment of their own actions. |
| 202. |
See previous comments |
| 203. |
Many ideas and programs are great in intent but do not generate RVUs/RWPs and in a capitated system in becomes difficult to incentivise patient safe behavior with a fixed funding stream |
| 204. |
Chief obstacle is that most current measures are of process rather than outcomes and that process metrics and methods are not always uniform. Secondary obstacle is lack of faith by physicians in ability of MCO's that prepare physician report cards are able to accurately measure performance, esp. with respect to outcomes. |
| 205. |
Changing from a culture of individule responsibility to a team/group responsibility for quality improvement. Understanding the principles of QI and how they apply to the practice of medicine. |
| 206. |
Physician must be placed in postion of responsibility with appropriate accountability when quality care is paramount. |
| 207. |
everyone always has a "full plate" and it is difficult to work in another safety project. |
| 208. |
large medical staff of 1400 inexperienced nurses, and nurse managers chosen for clinical rather than leadership skills |
| 209. |
It is mostly cultural, IMO. Most efforts are nominal. |
| 210. |
The main hospital I cover is a for-profit facility, and it easy to "believe" that the return to the shareholder supercedes interest in pursuing an aggressive quality agenda. I would love to see a comparison of for-profit vs. not-for-profit in this regard! |
| 211. |
Multiple parallel initiatives |
| 212. |
Physician suspicion and fear; lack of physician knowledge and participation, "name and blame" policies |
| 213. |
I believe that the overall impact of externally superimposed monitors is on the whole deleterious to health care rather than supportive. This is because: *The costs of such monitoring,in both money and personnel time are such that they divert significant resources from the very care which they are aimed at improving. *Monitors confuse the purpose of the guidelines from which they are derived. Most of the guidelines from which monitors originate -NHQMs, IHI etc - are very good, in that the represent a standard against which individual health care choices must be measured, and in which deviations should require justification. However turning such guidelines into monitors at once creates the important costs which are noted above, and lack the subtlety which is so much a part of health care decisions. This is, in my opinion, the reason why there is so little evidence for their efficacy. Given that such systems as Tracers and other forms of personal inspection exist, which have a greater capability for accuracy, whose costs are similar and which do not needlessly burden the hospitals, the use of such monitors seems redundant and unnecessary. |
| 214. |
none |
| 215. |
Quality is a means to an end. It is a way of travellig and should color all decisions made by the Board, the Administration, and the Medical Staff. Proper priority to safety is too often neglected in hospitals and physicians' offices. It is the system of care that must be overhauled so the each individual can do the best he can. |
| 216. |
main two barriers: 1. Administrators with no clinical background who don't understand the front lines of caring for patients. 2. Doctor's reluctance to change. |
| 217. |
instituting best practices is always challenging. In particular, care that crosses department lines is problematic. For example high ventilatory failure rates after scoliosis surgery can be nearly eliminated by pulmonary function testing but was not routinely done until units began refusing patients who had not been tested. |
| 218. |
When dealing with thousands of physicians, there is great diversity in their practices, making implementation of clinical and service quality initiatives extraordinarily difficult. The dollar is still the force that drives care, and it is increasingly difficult to effect safety and quality improvement if it does not significantly enhance financial return to the clinician. |
| 219. |
It is not the director's idea it is not a good idea. It is a very closed knit administractive circle where othersiders are not welcome. |
| 220. |
There has always been an ongoing commitment to quality of care. However, all the programs are resource intensive and the return on investment of time and energy is felt to be inadequately reimbursed. Many providers feel they are responsible for healthcare quality but that the programs are used to measure quality and provider care without actually having a commitment to improve the care only to prove that measurement took care to pass JCAHO or to look good on other programs |
| 221. |
It is needed, and the organizations that are best able to achieve superior levels of measurabel improvement, while be the ones that will thrive in the future. |
| 222. |
Getting docs to buy into quality and safety initiatives is single biggest challenge. Catastrophes happen so rarely that each doc thinks they must practice 'safe' medicine becasue "nothing like that has happened to me." |
| 223. |
inertia |
| 224. |
physician apathy |
| 225. |
proving to the senior leadership that quality is worth the investment in resources. public report cards have been helpful here. |
| 226. |
1- Culture: nursing and physician cultures need to change and openly accept measures and tools that promote safe health care provision such as EMR, CPOE, guidelines to reduce practice variation. 2- Feedback and performance improvement: Staff need to have feedback about their performnace, as well as necessary education and coaching to improve their performance. 3- Ongoing education is essential for health care workers to continue to provide safe, efficient and effective health care. 4- Healthy communication between clinical health care workers and non-clinical executives is essential for the success of the health care institution and the patient/consumer. |
| 227. |
Board of Directors is publicly elected (ie popularity contest); essentially clueless about running a health care organization--all have their own agenda which is not always putting quality first in spite of their public comments. Most have a serious conflict of interest |
| 228. |
Education with clear definitions. |
| 229. |
The Board receives a quality "dashboard" monthly. Administration is responsible for, with the Board, planning strategic quality initiatives. WE have created and filled a new executive position, Vice President for Quality. |
| 230. |
lack of CEO presence and CMO micromanaging process |
| 231. |
Doctors are very resistant to change and comparison of their clinical practice to best practices. |
| 232. |
Most practicing physicians are not convinced that we really can and need to do better-we still seem to believe it is someone else who is not doing a good job for our patients. |
| 233. |
Physician resistance. Lack of complete EMR, especailly CPOE,Hopsital processes that ease burden on hospital but increase burdens on physicians |
| 234. |
I am so disgusted b the total lack of commitment to patient safety demonstrated by our older physicians. They are so invested in the status quo, and their percieved position of power, that they are THE major obstacles to positive change in this small rural hospital. |
| 235. |
I don't think the difference in a culture of Safety and culture of Quality is distinct enough yet in people's mind. We can be putting quality improvement measures in place, and still be unsafe. We need to do both. |
| 236. |
It is so difficult to keep up with internal and external drivers of patient care safety and quality with shrinking reimbursements and the ever-increasing numbers of medically indigent patients presenting themselves to us. Our health care "system" is fundamentally broken, and the current administrations in Washington DC, and in most states, are doing nothing to fix the problems. |
| 237. |
We in Ascension Health are making a difference. By concentrating on a few critical areas for safety-quality initiatives, aligning incentives throughout the organization, committing the needed resources, choosong bold, audacious goals (the elimination of preventable death and injury) there is success. We've seen 10-20% reductions among patients admitted for other than end-of-life care, as well as reductions in the numbers of ventilator associated pneumonias, central line blood stream infections, perinatal injuries, falls, pressure ulcers, adverse drug events, and harm in the ICU. |
| 238. |
We are a group practice owned by the hospital. When I asked for some funding and support for quality initiatives, they said that the outpatient space is not their focus... so no help from them. |
| 239. |
Our primary care physicians, though well trained and motivated, are already underpaid and struggling with time issues to keep their practices in the black. Getting them to take time to work with our clinical managers and to introduce new safety/quality initiatives is the understandable barrier. My hope is that we can increase the amount of capatation payment to allow them a bit more freedom to work with our case managers. |
| 240. |
Improvements in quality health care are often a statistical exercise. Because of this the usual caveats need to exercised--the data is only as good as the databases from which it is extracted, and the patient retains the right to autonomy. Pay for performance still has a long way to go in terms of achieving the targetted successes in performance improvement and patient safety, because most physicians are already doing what they think is best in these areas. As a result you end up with a huge bureaucracy to warehouse and manage the data. |
| 241. |
Juggling all the various regulatiory requiements Federal, State, Insurance), along with the self-intesrests of physicains, staff, administrators,in an environment of stagnant or decreasing reimbursment, and an demografic with 71% M'Care/ M'Caid and 11% "Self-Pay." |
| 242. |
Educating department chairs and medical staff about the details of safety and quality initiatives and getting their ownership in the process is a challenge. Also improving communication between all stakeholders (nurses, doctors, pharmacy, patients) is always challenging. Prioritizing which projects needing more focus or financial resources is difficult at times. Maintaining the urgency to not only implement projects, but to keep them going and to continue to monitor their progress is difficult. |
| 243. |
It is clear that in order to improve quality and safety we must reward the adoption of evidence based medicine and adhereance to quality guidelines. This will not happen unless meaningful financial incentives are put in place. Right now, physician income and hospital revenue is driven by volume and procedures, not quality, appropriateness, necessity or outcomes. We must change the reimbursement system to reward quality and safety if we can ever expect meaningful improvement. |
| 244. |
Lack of alignment of goals across the healthcare delivery system and the multiple different system silos involved in the care of any individual patient makes the implementation of systemic process change difficult. |
| 245. |
Quality costs money in the short term, but will eventually save money overall. We have to get past our know-it-all egos as physicians, and apply what science there is in medicine to the care of our patients. |
| 246. |
quality should report to the board not to the ceo or administrator; financial incentives for quality are lacking or non existant; most boards become finance driven because dollars are easy to understand and quantify; a CEO who makes a big profit the board will assume quality; a CEO who breaks even or loses money will be assumed to have performed poorly even if high quality was delivered; need to separte quality reporting from financial reporting to the board. Make the board see both sides and decide at the board level. If these decsions are left to admin; relatively short term financial goals almost always drive the priorities |
| 247. |
Decreasing the issues of malpractice will help to engage physicians in looking deeper into practicing these quality issues daily. |
| 248. |
Sometimes it is best to just go ahead and do the right thing and let any negative fallout do just that-- fall out. |
| 249. |
Board on Boards plank of IHI 5 million lives campaign is step to opening doors for improvement. NQF harmonized safe practice #1 is major step forward from Leapfrog, CMS, AHRQ, JCAHO meausrement specifications. |
| 250. |
Physician buy-in is the biggest obstacle. |
