The multiple facets of physician The multiple facets of physician decision-making under uncertaintydecision-making under uncertainty

Katharina Janus, Ph.D.Katharina Janus, Ph.D.Harkness Fellow in Health Care PolicyHarkness Fellow in Health Care Policy

Department of Health Policy and ManagementDepartment of Health Policy and Management

Columbia University, New YorkColumbia University, New York

Orlando, June 2007Orlando, June 2007

OverviewOverview

Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and

practice in the U.S. and Germanypractice in the U.S. and Germany

1

10

100

1,000

10,000

100,000

1,000,000

Untrustworthy Quality of CareUntrustworthy Quality of Care

U.S Airline flight fatalities/U.S. Industry Best of Class

Airline baggage handling

1(69%)

2(31%)

3(7%)

4(.6%)

5(.002%)

6(.00003%)

Overall Health Care Quality in U.S.

(Rand Study 2003)

IRS Phone-in Tax Advice

NBA Free-throws

Sources: modified from C. Buck, GE; Dr. Sam Nussbaum, Wellpoint; & Mark Sollek, Premera

level (% Defects)

Def

ects

per

mil

lio

n

∑

Fair Reliability

High Reliability

Long-Term Goals

Short-Term Goals

Foundation

Build Trust / CollaborationBuild Trust / Collaboration

Structure / ProcessStructure / Process

OutcomesOutcomes

ImproveImproveMember Health Member Health

ValueValue

Quality Vision for P4P Programs in the U.S.Quality Vision for P4P Programs in the U.S.

Source: Nussbaum P4P Summit 2006

Limitations and challenges of P4PLimitations and challenges of P4P

Ceiling effects (high versus low performers)Ceiling effects (high versus low performers) Organizational scale (small practices)Organizational scale (small practices) Costs (too early to tell???)Costs (too early to tell???) Quality (some positive evidence…)Quality (some positive evidence…) Caveats (selection bias, definition of Caveats (selection bias, definition of

measures, loss of holistic approach to care, measures, loss of holistic approach to care, socio-demographic fine-tuning)socio-demographic fine-tuning)

Janus, K., Brown, L.D. (2007), Medicare as Incubator for Innovation in Payment Policy, Journal of Health Politics, Policy and Law, vol. 32, no.1: 293-306.

A new approach is needed…A new approach is needed…

BecauseBecause specialties are faced with significantly specialties are faced with significantly

different decision-making situations, have different decision-making situations, have different cultures and, thus, respond different cultures and, thus, respond differently to incentivesdifferently to incentives

a large part of medical decision-making does a large part of medical decision-making does not refer to routine treatment decisions, but not refer to routine treatment decisions, but rather to adhoc situations that are not rather to adhoc situations that are not standardizable and underlie a high degree of standardizable and underlie a high degree of uncertaintyuncertainty

Because one size does not fit all!Because one size does not fit all!

OverviewOverview

Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and

practice in the U.S. and Germanypractice in the U.S. and Germany

ObjectivesObjectives

What are the challenges of a physician operating under high What are the challenges of a physician operating under high uncertainty in a system?uncertainty in a system?

Are there Are there general decision-making patternsgeneral decision-making patterns of physicians in of physicians in case of unexpected events and what do they look like?case of unexpected events and what do they look like?

How do physicians How do physicians manage prospectivelymanage prospectively uncertainty and the uncertainty and the potential for error in their daily work life?potential for error in their daily work life?

What is the role of informal organization (e.g. event What is the role of informal organization (e.g. event discussions in the hallway) when discussions in the hallway) when dealing with unexpected dealing with unexpected eventsevents? Could/Should it be more formalized and structured?? Could/Should it be more formalized and structured?

Building on the derived decision-making patterns, how can the Building on the derived decision-making patterns, how can the ‘unpredictable’ be made more ‘predictable?’ What do ‘unpredictable’ be made more ‘predictable?’ What do ‘guidelines’ for unexpected events look like? What is the role ‘guidelines’ for unexpected events look like? What is the role of the human and what is the role of the system component in of the human and what is the role of the system component in these guidelines? How can we incentivize these guidelines?these guidelines? How can we incentivize these guidelines?

How can the strategies be implemented?How can the strategies be implemented?

OverviewOverview

Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and

practice in the U.S. and Germanypractice in the U.S. and Germany

MethodologyMethodology

Physicians from four specialties (surgery, general Physicians from four specialties (surgery, general internal medicine, anesthesiology and psychiatry) have internal medicine, anesthesiology and psychiatry) have been recruited for qualitative interviews at New York been recruited for qualitative interviews at New York Presbyterian Hospital and Weill/Cornell Medical Center.Presbyterian Hospital and Weill/Cornell Medical Center.

These four specialties represent a useful continuum for These four specialties represent a useful continuum for the degree of treatment processes that are considered to the degree of treatment processes that are considered to be ‘routine’ and non-routine.be ‘routine’ and non-routine.

Interviews were conducted face-to-face and were tape-Interviews were conducted face-to-face and were tape-recorded, transcribed and evaluated using a content recorded, transcribed and evaluated using a content management software.management software.

40 interviews are currently in the database. Further will 40 interviews are currently in the database. Further will follow.follow.

OverviewOverview

Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and

practice in the U.S. and Germanypractice in the U.S. and Germany

Uncertainty in decision-making versus Uncertainty in decision-making versus frequency of events across specialtiesfrequency of events across specialties

Frequencyof UnexpectedEvents

Uncertaintyin Decision-

Making

Anesthesia Surgery Internal Medicine Psychiatry

Stages of decision-making under Stages of decision-making under uncertaintyuncertainty

ProspectiveDecision-

Making

ActualDecision-

Making

RetrospectiveDecision-

Making

HumanComponent

Learning Support Reporting

SystemComponent

Prospective decision-makingProspective decision-making

ResourcesResources Articles, textbooks and the internetArticles, textbooks and the internet Colleagues and advisorsColleagues and advisors Equipment and pharmaceuticalsEquipment and pharmaceuticals Patient information and patient engagementPatient information and patient engagement

Reflection and experienceReflection and experience Risk assessment and prioritizingRisk assessment and prioritizing Acceptance of the “Random“Acceptance of the “Random“

Actual decision-makingActual decision-making

ResourcesResources Articles, textbooks and the internetArticles, textbooks and the internet Colleagues and advisorsColleagues and advisors Equipment and pharmaceuticalsEquipment and pharmaceuticals Patient information and patient engagementPatient information and patient engagement

Reflection and experienceReflection and experience Prioritizing under constraintsPrioritizing under constraints StressStress

Retrospective decision-making – Retrospective decision-making – how to deal with eventshow to deal with events

Formal processes for the unexpectedFormal processes for the unexpected Informal processes for the unexpectedInformal processes for the unexpected

Informal human interaction in generalInformal human interaction in general Physician culture in particularPhysician culture in particular

Blame/shameBlame/shame AccountabilityAccountability Reciprocity/ mutual protectionReciprocity/ mutual protection DetachmentDetachment Openness to failureOpenness to failure

System Factor – example MERSSystem Factor – example MERS(Medical Event Reporting System)(Medical Event Reporting System)

General reporting obligation (self/professionalism, patient, organization)General reporting obligation (self/professionalism, patient, organization) Incentives for reporting or not reportingIncentives for reporting or not reporting

AnonymityAnonymity BenchmarkingBenchmarking Connectivity and work process integrationConnectivity and work process integration CostCost CultureCulture Definition of eventsDefinition of events External professional organizationExternal professional organization Feedback/ Information accessFeedback/ Information access Immediate staff/technical supportImmediate staff/technical support LitigationLitigation Medical trainingMedical training Monetary incentivesMonetary incentives Organizational accountabilityOrganizational accountability Paperwork/timePaperwork/time Personal accountabilityPersonal accountability Threats by the organizationThreats by the organization Usability/tutorialUsability/tutorial

Reporting value for specialtiesReporting value for specialties

OverviewOverview

Rationale for the projectRationale for the project ObjectivesObjectives MethodologyMethodology Preliminary findingsPreliminary findings Implications for policy, delivery and Implications for policy, delivery and

practice in the U.S. and Germanypractice in the U.S. and Germany

Implications and LearningsImplications and Learnings

Before designing incentive systems we have to Before designing incentive systems we have to understand physician decision-making.understand physician decision-making.

Managed care (Standard Operating Procedures) Managed care (Standard Operating Procedures) does not apply to decision-making under does not apply to decision-making under uncertainty.uncertainty.

But: Unexpected events derive from intrinsic But: Unexpected events derive from intrinsic uncertainty.uncertainty.

Errors in medicine are not only a system problem, Errors in medicine are not only a system problem, the physician factor is crucial. Managing uncertainty the physician factor is crucial. Managing uncertainty has its own challenges.has its own challenges.

But: Systems can support physician decision-But: Systems can support physician decision-making in different ways to enhance quality of care.making in different ways to enhance quality of care.

““The practice of medicine is The practice of medicine is an art based on science“an art based on science“

Sir William OslerSir William Osler

Thank you very much for your attention!

Special thanks go to:Lola Adedokun

David BlumenthalAlexander Bock

Larry BrownMichael Gaitanides

Annetine GelijnsSherry GliedJack Rowe

Tom RundallShoshanna Sofaer

Mario Weiss

…and The Commonwealth Fund!